Physician Suicide Log
Please remember that any information is useful, if you cannot fill out all details please fill out what you can. Thank you!

Your name
Leave blank if you wish to remain anonymous
Your email address
Leave blank if you would prefer not to be contacted
Name of physician/medical trainee
Age or DOB if known
Sex
Clear selection
Date of Death (Approx if unknown)
Specialty
Level of Training (Med1-4, R1-5, Fellow, staff)
Please note what year of training the person was in, or if they were staff/finished training.
Place of Birth
Province of Death
Confirmed Suicide?
Clear selection
Contact Info for (friend/family/Next of Kin)
Manner of suicide
Known or Suspected Circumstances/Factors (eg harassment, problems with licensure, exam failure, issues of ethnicity, sexual orientation, IMG, no supports, work politics, etc)
Memorial/Donation Page
How was this shared with the medical community?
Did you feel this was adequate?
Any recommendations you have for improving how the situation was dealt with (reporting, sharing with colleagues, funeral/memorial events, etc)
Any other comments?
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