Indiana LOSS Team Application - MHAI Stan W DeKemper Training Institute

- Step 1 of 8

1. TELL US ABOUT YOUR PROPOSED LOSS TEAM

Name of LOSS Team *

County(ies) to serve in year 1 *

County(ies) to serve in year 2-3

County(ies) to serve in year 4-5

2. PLEASE PROVIDE INFORMATION ON YOUR REGIONAL INDIANA SUICIDE PREVENTION COALITION (ISPC)

Name *

Leader Name *

First

Last

Email *

Do you have a current relationship with them?

3. PLEASE PROVIDE US DATA RELATED TO YOUR COUNTY:

Indiana Department of Health Stats Explorer
Center for Disease Control and Prevention Database

Total # of recorded suicides (2015-2020) in

County(ies) – Year 1 *

County(ies) – Year 2-3

County(ies) – Year 4-5

4. TELL US ABOUT YOUR TEAM

Name of Team Coordinator *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell # *

Landline #

Work #

Emergency Contact Name *

First

Last

Cell # *

Name of Team Co-Leader *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell # *

Landline #

Work #

Emergency Contact Name *

First

Last

Cell # *

Name of Team Co-Leader *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell # *

Landline #

Work #

Emergency Contact Name *

First

Last

Cell # *

Name of On Call Person *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Cell # *

Landline #

Work #

Emergency Contact Name *

First

Last

Cell # *

5. TEAM ADMINISTRATION: Fiscal Agent for team must be a not-for-profit

Agency *

Contact Person *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

6. HELP US UNDERSTAND YOUR BUDGETARY NEEDS/ESTIMATES

Provide estimated dollars you believe you will spend in the below spaces.

Year 1

Mileage

Uniforms

Resources at the Scene and for Survivor Follow up

Referral source Toolkit

Mints

Water

Book for loss survivors – Seeking HOPE

Journal

Candle

Other

Training Needed - provide the approx number of volunteers who need the following trainings

LOSS Team (6 virtual and 1 in-person workshop)

Mental Health Awareness

ASIST

safeTALK

QPR

7. COMMUNITY GOVERNMENTAL LEADERSHIP

Name of Mayor *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Do you have a current relationship with this person?

Name(s) of County Council Member

Address

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a current relationship with this person?

Name of County Coroner *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Cell #

Do you have a current relationship with this person?

Name of Assistant Coroner *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Cell #

Do you have a current relationship with this person?

Name of City Police Chief *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Do you have a current relationship with this person?

Name of County Sheriff *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Do you have a current relationship with this person?

Name of County Fire Chief *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Work #

Do you have a current relationship with this person?

Name of Funeral Home #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Name of Funeral Home #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Name of Funeral Home #3

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Community Mental Health Agency #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Community Mental Health Agency #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Community Mental Health Agency #3

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Mental Health Agency and/or Therapist #1

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Mental Health Agency and/or Therapist #2

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Mental Health Agency and/or Therapist #3

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Mental Health Agency and/or Therapist #4

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Media Partner #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Media Partner #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Media Partner #3

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Faith Partner #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Faith Partner #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

Faith Partner #3

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Do you have a current relationship with this person?

If you do not have current partnerships with the categories listed above, please describe how you plan to create, and sustain, these partnerships:

8. PROVIDE INFORMATION ON YOUR AREA SURVIVORS OF SUICIDE (SOS) SUPPORT GROUPS

SOS Support Group #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Meeting times & location

SOS Support Group #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Meeting times & location

If you do not have current support groups listed above, please describe how you plan to approach your plan without these groups:

9. BUSINESS PARTNER(S)

Biohazard #1

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

Biohazard #2

Contact person

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Work #

If you do not have current partnerships with the categories listed above, please describe how you plan to create, and sustain, these partnerships:

10. PLEASE PROVIDE US INFORMATION ON VOLUNTEERS ASSOCIATED WITH THIS PROPOSED TEAM

Name #1

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #2

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #3

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #4

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #5

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #6

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #7

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #8

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #9

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #10

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #11

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

Name #12

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell #

Loss Survivor

# Of years since the loss

Training completed and date

11. TEAM VOLUNTEER DEMOGRAPHICS

Provide the # of volunteers that meet the demographics in the below spaces

PLEASE DESCRIBE YOUR TEAM MEMBERS

Gender Identity

Male

Female

Non-Binary

Race

Asian

White

American Indian

African American

Hispanic/Latino

Other – Indicate

Age

Age 18-24

Age 25-34

Age 35-44

Age 45-54

Age 65+

Please list team members names who speak any languages other than English and their fluency level.

RESOURCES

List what will be delivered to survivors on scene. Please note items that are evidence-based or considered promissory practice items.

PLEASE DESCRIBE THE SUSTAINABILITY PLAN FOR YOUR LOSS TEAM

What is your LOSS Team’s innovative approach to funding/donations to maintain financial needs after the five-year grant period? (Examples – sponsorships, community foundation partnerships, fundraising events, etc.

LETTERS OF COLLABORATION ARE REQUIRED FOR YOUR TEAM APPLICATION. Please include letters of collaboration from a local law enforcement agency and/or your local Coroner’s office stating their plans to work alongside your team to support your LOSS teams success with your application.

Click or drag files to this area to upload. You can upload up to 5 files.

Allowed file format: .pdf

1. TELL US ABOUT YOUR PROPOSED LOSS TEAM

2. PLEASE PROVIDE INFORMATION ON YOUR REGIONAL INDIANA SUICIDE PREVENTION COALITION (ISPC)

3. PLEASE PROVIDE US DATA RELATED TO YOUR COUNTY:

4. TELL US ABOUT YOUR TEAM

5. TEAM ADMINISTRATION: Fiscal Agent for team must be a not-for-profit

6. HELP US UNDERSTAND YOUR BUDGETARY NEEDS/ESTIMATES

Year 1

7. COMMUNITY GOVERNMENTAL LEADERSHIP

8. PROVIDE INFORMATION ON YOUR AREA SURVIVORS OF SUICIDE (SOS) SUPPORT GROUPS

9. BUSINESS PARTNER(S)

10. PLEASE PROVIDE US INFORMATION ON VOLUNTEERS ASSOCIATED WITH THIS PROPOSED TEAM

11. TEAM VOLUNTEER DEMOGRAPHICS

RESOURCES

PLEASE DESCRIBE THE SUSTAINABILITY PLAN FOR YOUR LOSS TEAM

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