Serious Injury or Death Line of Duty Form (Cambridge PD)

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To all members of the Cambridge Police Department:

The Peer Support team has been working on an information sheet for your families to be kept in a safe in the peer support office. This form would only be used when an officer is killed in the line of duty, or the officer suddenly passes away. We are asking all members to complete the form so it will be less of a burden on your family as they navigate through a very difficult time. This information would be provided to your significant other or family member by the liaison assigned to your family. Each member of the department is assigned to a member of the peer support team and these members will be conducting check ins with you periodically as we navigate through the difficult times of putting on the uniform and coming to work. The last three to five years of policing has added stressors to our daily lives that someone in the private industry may not be able to relate to. Our goal is for each member to have a healthy career and be able to enjoy a long retirement.

A peer support member will be contacting you to voluntarily fill out the form, seal it in your envelope provided, and have you sign the envelope before it being secured into the locked safe. This safe is only accessed by a member of the peer support team at the time of your unfortunate death. No member of the command staff or personnel will have access to the safe or your information!! The form has been attached to this email if you prefer to fill it out beforehand or a paper copy will be provided by the peer member.

The form is simply looking for the following information:

Name, Address, and you home telephone number
Names of your family members
Who you would like to make notification to your family
Funeral service provider and ceremonial information
Special request section if you wanted to provide any banking information, life insurance, etc

If you prefer NOT to complete the form, we will simply ask that you seal and sign the envelope and give it back to the peer support member to be placed in the safe. This will ensure that all members of the department have an opportunity to complete the form, and no one is forgotten.

We have attached a copy of the form if you would like to fill it out ahead of time or just wanted to see what information would be provided to your family.

Thanks for your time and let’s hope we never have to use the form, but we have it in case we do!!
Cambridge Police Peer Support Team

CPD Peer Support Unit Serious Injury/Line of Death Form

Any information provided within this form will be used in the event of serious injury/death in the line of duty. This form will ONLY be used to assist your brother and sister officers in honoring your wishes and is not intended to be used as a legal document/will. In addition, it may express your intent to NOT have any type of police-oriented service, if you so desire. Please note, all this information is voluntary, and you may include as much or as little as you wish. Once completed, we would like officers to submit this form to the CPD Property Unit in a sealed envelope. The form will be stored in a locked safe in the Property Unit and can only be accessed by a Peer Support Coordinator. If this form requires any update or change, please contact a Peer Support Coordinator for assistance. If you feel comfortable you can also leave a copy of the form with a coworker/friend. On the day of your retirement, shred it!

Name

First Middle Last

Address

Street Address City State ZIP Code

Your Home Phone Number

Family Information

Spouse/Significant Other Name

Address and Telephone If different than above:

Employer, Work address and Telephone number

Names and dates of birth of your children

Tap the ⨁ icon to add additional children

Name

DOB

If you are divorced, do you want a police representative to contact your ex-spouse? If so, please provide information about your ex-spouse.

Please list the name, address, and telephone numbers of your children who live outside the family home and key relatives (parents, siblings, in-laws, etc.) below:

Tap the ⨁ icon to add additional relatives

Name

Address

Phone

Relationship

Notifications

I would like the following individual(s) to make notification to my family:

Please list the persons you would like to be contacted by a police representative in the event of serious injury or death in the line-of-duty. Begin with the first person you would like to have notified in descending order.

Tap the ⨁ icon to add additional relatives

Name

Address

Phone

Relationship

Is there anyone you would like contacted to assist your family, or to assist with funeral arrangements, or related matters that is not listed above? This person should be knowledgeable concerning your life insurance representatives, location of your will etc.

Is there anyone you would like to accompany the police representative when the notification is made to your immediate family? If someone other than a Cambridge Police Officer, please include telephone number.

Funeral Services:

Please list preferences you may have regarding funeral arrangements:

Funeral Home

Church or Synagogue

Cemetery

Are you a Veteran of the U.S. Armed Services?

Yes

Do you wish to have a military funeral, if entitled by the Department of Veterans Affairs?

Yes

Do you wish to have a Law Enforcement Funeral?

Yes

I wish to be wearing

Class A Uniform

Military

Suit

Other

I wish to be wearing (other):

If so, do you have any special instructions (cremation, interment or entombment)?

Does the Cambridge Police Department have your permission to honor your service to the city in a manner they deem appropriate?

(This may include honor guard service, officer march to cemetery; service in a large venue to accommodate fellow brother and sisters from outside agencies and/or government representatives i.e., Town Selectmen, state Governor, and or state representatives).

Yes

If YES please list any additional guidance

(i.e., social media release, press release, etc.)

Is there any particular aspect of a law enforcement service you do NOT wish to have?

(For example, bagpipes are commonly played at public service funerals, but some may wish not to have them).

Is there any particular aspect of a law enforcement service you DO wish to have?

(For example, elected officials commonly attend funerals for police and fire fighters who give the ultimate sacrifice. Some people may want to ensure certain officials are included and invited or conversely not included or invited).

Please list memberships in other law enforcement, religious, or community organizations (i.e., Rotary; Freemasons; Elks etc.) that you want included in your service:

Are there any other special requests or directions not included in this form you would like followed upon your death?

Signature

Date

MM slash DD slash YYYY