Indiana LOSS Team Application - Expansion - Indiana Association of Peer Recovery Support Services

- Step 1 of 8

1. TELL US ABOUT YOUR EXISTING LOSS TEAM

Name of LOSS Team *

County(ies) *

Expansion County(ies)

2. EXPANSION COUNTY(IES) 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

Existing LOSS Team County(ies) *

Expansion LOSS Team County(ies)

4. TELL US ABOUT YOUR EXISTING LOSS TEAM MANAGEMENT

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 # *

What is the status of the existing county LOSS Team? *

Active
Non-Scene Response in Place
In Process

If the existing County LOSS Team status is anything other than "Active and responding on scene when activated by LE/Coroner" Please explain why you are ready to expand into future county(ies)

EXPANSION COUNTY 1 Point Person 1:

Name *

First

Last

Email *

Cell

Landline

Emergency Contact Name *

First

Last

Cell

Point Person 2:

Name *

First

Last

Email *

Cell

Landline

Emergency Contact Name *

First

Last

Cell

EXPANSION COUNTY 2 Point Person 1:

Name *

First

Last

Email *

Cell

Landline

Emergency Contact Name *

First

Last

Cell

Point Person 2:

Name *

First

Last

Email *

Cell

Landline

Emergency Contact Name *

First

Last

Cell

5. EXISTING LOSS 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.

SUBMIT A DETAILED BUDGET AS A SEPARATE ATTACHEMENT INCLUDING 1) TYPE OF EXPENSE, 2) DOLLAR AMOUNT, AND 3) DESCRIPTION OF EXPENSE. EXAMPLES OF TYPES OF EXPENSES: STAFF, VOL TRAINING, VOL UNIFORMS, VOL "OTHER" (BACKGROUND CHECK, MILEAGE REIMB, ETC), AND SURVIVOR RESOURCES *

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7. COMMUNITY PARTNERS IN EXPANSION COUNTY(IES)

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 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?

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?

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?

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?

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

8. SURVIVORS OF SUICIDE SUPPORT GROUP(S) IN EXPANSION COUNTY(IES)

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) IN EXPANSION COUNTY(IES)

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. VOLUNTEER INTEREST IN EXPANSION COUNTY(IES)

Name #1

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #2

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #3

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #4

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #5

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #6

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #7

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #8

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #9

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

Name #10

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

County

Cell #

Loss Survivor

# Of years since the loss

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.

THREE LETTERS OF COLLABORATION ARE REQUIRED. One from the local law enforcement agency and/or Coroner's office in each expansion county stating their plans to work alongside your team to support your LOSS Teams success. And two letters from other community partners in each expansion county who will actively work with you to launch a LOSS team. At least one of these two letters should be from a mental health agency. If a collaboration letter is from an agency that is not local to the county you will be serving in (i.e., state police), the letter should explain how the non-local agency will ensure you are called to local suicides, and how the non-local agency works with county and city first responders.

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