Please note that all fields marked with an asterisk (*) are required to provide relevant and accurate reporting. These fields are not confidential in that they will be used for aggregate reporting purposes. For instance, it will be reported the number of males and females who have died by suicide, the number of states with the highest suicide rates, etc.
Items without asterisks are not required. If provided, this information is strictly confidential and will not be disclosed without prior consent.
If you wish to report the name of the first responder you may, this will help with the vetting process but will be kept confidential. At no time will this piece of information be shared without your permission. This is not required for reporting purposes.
Note: Contact information for the person reporting is requested so that we may ensure the information is accurate and reliable. We will not contact you unless absolutely necessary.
Name of First Responder Gender * Race Race Unknown American Indian or Alaska Native Asian Black or African American Caucasian Hispanic Date of Death *
MM slash DD slash YYYY
Age at time of death * Years of Service Rank Chief Executive (ex. Fire Chief) Senor Executive (ex. Deputy Asst. / Asst. Chief ) Mid-Manager (ex. Division / Battalion / District Chief ) Line Supervisor (ex. Captain / Lieutenant / Sargeant / Engineer) Firefighter (includes Fire/EMT and Fire/Medic) On or Off Duty? At time of death Unknown On Duty Off Duty Military Veteran Marital Status Married Single Common Law Marriage Separated Widower Divorced Domestic Partner Engaged Life Partner Other Any Children? Did the first responder have children? Unknown Yes No Number of Children Profession Duty Status Active Admin Leave Fired FMLA Light Duty Medical Leave Medically Retired PTSD Leave Resigned Retired Suspended Terminated Unpaid Leave Other Name of Department / Agency (i.e. Boston Fire Department) How many months had the first responder been separated from the department? City State * Manner of Death Firearm Hanging Vehicle Asphyxiation Drug Overdose Carbon Monoxide Other Had the person sought help? Was there a history of job related PTSD? Were there prior suicide attempts? Was this person under investigation at the time of death? If available, and applicable, we appreciate any links to the death that can provide verification of the suicide or details about the firefighter. This includes a link to the obituary. All of this is kept confidential, no matter how public the suicide, unless the family provides permission to share. Verification Link Verification Link 2 Is there anything else you would like us to know? On occasion, we send cards and small gifts, such as Christmas ornaments, to family members. Please add the mailing address, family relation type (parent, spouse...) and, any other information (names, ages and gender) below. Again, this information is not shared in any way and is solely used for support and remembrance. Mailing addresses Memorial Page Photo Upload Max. file size: 100 MB.
By submitting your photo, you are giving Red H.E.L.P. explicit permission to use the photo on our website and facebook page. Red H.E.L.P. assumes that you have authority to grant permission to use the photo. If you have questions about photo use, please note that in the text field above and we will contact you via e-mail.
I am a Family Member Organization Significant Other Friend Coworker Other Red H.E.L.P. Your contact information Full Name Can we contact you for more information if needed?
We will only contact you if there is something pressing that we feel we need to ask. For instance, if a future study requires more information. Otherwise, we will not contact you in any way.
This field is for validation purposes and should be left unchanged.