STUDENT DEATH REPORT FORM
This report is to be completed, in full, by Student Affairs as follows:
1. Student Name: _______________________________________________
First Middle Last
2. Does any other student have the same name?
If so, give Identification number: ________________________________
3. Student identification number: ___________________________________
4. Student campus address: ______________________________________
5. Student permanent address: ____________________________________
6. Time, date and place of death: ___________________________________
7. Reason for death (give as much detail as is known to be factual:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
8. Witness(es), Address, Telephone no.: _____________________________
___________________________________________________________
___________________________________________________________
9. Name of parent, guardian, spouse or relative _______________________
___________________________________________________________
Address:____________________________________________________
Telephone no: _______________________________________________
10. Notified by: _________________________________________________
Time: ________________ Date: _________________________________
11. Immediate instructions given by parent, guardian, spouse or relative:
___________________________________________________________
___________________________________________________________
___________________________________________________________
12. Has the next-of-kin given authorization that the above information may be
released to the media:
Yes ___ No ____ If yes, what time: ________ Date: ____________
13. Hospital (s) involved: _________________________________________
14. Who was contacted – immediate notification:
Parent, spouse or next-of-kin:___________________________________
Principal: ___________________________________________________
Executive Group: _____________________________________________
Academic Dean: ______________________________________________
Academic Department: ________________________________________
Advancement Office: __________________________________________
Athletics: ___________________________________________________
Counselling: ________________________________________________
Health: ____________________________________________________
Ministry: ____________________________________________________
Registrar: __________________________________________________
Residences (if applicable): _____________________________________
Roommate (if applicable): ______________________________________
Security: ___________________________________________________
SRC President: ______________________________________________
Partner of deceased: __________________________________________
Others: ____________________________________________________
FUNERAL ARRANGEMENTS:
______________________________________________________________
Memorial Service Time: ____________________________________________
Date: _______________________________
Place: _________________________________________________________
Other University Action (ie. Scholarship Fund): _________________________
______________________________________________________________
Personal belongings packed by: _____________________________________
Time: _____________ Date: ____________________________________
Shipped via: ___________________________________________________
Time: _____________ Date: ____________________________________
Withdrawal Form processed by: _____________________________________
Time: _____________ Date: ____________________________________
Tuition/Room/Board refund processed by: _____________________________
Time: _____________ Date: ____________________________________
Letter of Sympathy written by: ______________________________________
Time: ______________ Date: ___________________________________
Letter of Sympathy sent on: ________________________________________
Report completed by: _____________________________________________
Date: __________________________________________________________
October 20, 1995
Extracted from Mount Saint Vincent University
