Due to technical difficulties, the campus Death Response web site is currently unavailable. Please accept our sincere apologies. To report a death of a member of the UCB campus, please fill out the information below and email to : Wendy Nishikawa, Work/Life Manager, at wnishikawa@uhs.berkeley.edu. Wendy is also the contact for any additional questions regarding resources and protocols for a coordinated, considerate response to death in the campus community.

DEATH REPORT CONFIDENTIAL

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INFORMATION ABOUT THE DECEASED
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1. Last Name:
2. First Name:
3. Gender:
4. Date of Birth:
5. Date of Death/Date Discovered:
6. Location of Death:
7. The Deceased was: (e.g. emeriti, retiree, staff, faculty, grad student, etc.)
8. Division/Unit/Department of Deceased:
9. Job Title and/or Working Title:
10. Employee or Student ID Number:
11. For Students-major and degree in progress:
12. For Students-Projected date of degree completion:
13. Date of initial employment or enrollment (month/year):
14. Was the Deceased still enrolled/employed?:
15. If they were not still enrolled or employed, when did they leave campus (month/year):
16. Name of Deceased's Supervisor or Department Chair:
17. Supervisor/Chair's Phone:
18. Supervisor/Chair's Email:

INFORMATION ABOUT THE PERSON WHO REPORTED THE DEATH TO THE UNIVERSITY

19. Name:
20. Relationship to the Deceased:
21. Mailing Address:
22. Phone:


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COORDINATOR OF NOTIFICATION PROCESS
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23. Name:
24. Department/Office:
25. Email:
26. Phone:
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END OF DEATH REPORT