EmailMeForm
UCBerkeley Death Report - Confidential
This report should be completed and sent to the appropriate office within 24 hours. The report should be forwarded within this timeframe, even if you are not able to fill in every field of the form. PLEASE INFORM THE DEPARTMENT OR DIVISION POINT OF CONTACT OF RECEIPT OF THIS REPORT.
INFORMATION ABOUT THE DECEASED
Last Name of Deceased
*
First Name
*
Middle Initial
Date of Death
*
MM
/
DD
/
YYYY
Date of Birth
*
MM
/
DD
/
YYYY
Location of Death
(e.g. home, university property (including housing), hospital...)
The Deceased was:
*
Staff
Retiree
Retiree who was still working on campus
Faculty/Academic
Emeritus
Emeritus who was still working on campus
Post Doc / Visiting Scholar
Undergrad Student
Graduate Student
Division/Unit/Department
*
Job Title and/or Working Title (if applicable)
Employee or Student ID#
*
For Students: List Major and Degree in Progress
For Students: Projected date of degree completion
Date of initial employment/enrollment
(month/year)
Was the Deceased still enrolled/Employed?
Yes
No
If they were not still enrolled or employed, when did the deceased leave campus?
(month/year)
Name of Supervisor or Department Chair
*
Supervisor/Chair's Phone
*
Supervisor or Chair's Email
*
INFORMATION ABOUT INDIVIDUAL WHO REPORTED THE DEATH TO THE UNIVERSITY
Name
*
Relationship to the deceased
*
Contact Information (phone) OR...
*
Contact Email
DIVISION OR DEPARTMENT POINT OF CONTACT INFORMATION
Division or Department Point of Contact Name
*
Department/Office
*
Division or Department Point of Contact Email
*
Phone
*
