Report | Nov. 14, 2014

Department of Defense Suicide Event Report (DoDSER) Data Quality Assessment



The Department of Defense Suicide Event Report (DoDSER) is the system of record for health surveillance related to suicide ideations, attempts, and deaths. This assessment focused on decreasing the number of “don’t know” responses on suicide death submissions by identifying changes to policy, training, or oversight. We also examined the sharing of DoD medical information with the Department of Veterans Affairs (VA).


We identified seven topics for DoDSER submissions improvement:

  • DoDSERs are submitted prematurely,
  • DoDSER data collection is stovepiped,
  • technical questions presented challenges for non-technical DoDSER submitters,
  • user/commander feedback on DoDSER data is limited,
  • Military Crisis Line staff lacks access to relevant military healthcare information,
  • DoDSER data is not shared with the VA, and
  • Military Criminal Investigative Organizations participation in the DoDSER process is inconsistent.


We recommend the Department of Defense improve the processes for collecting DoDSER information and submitting DoDSER data:

  • Submit final DoDSER data after the Armed Forces Medical Examiner has completed the death investigation.
  • Establish a multidisciplinary team approach to data collection to ensure accuracy.
  • Improve subject matter expert participation in DoDSER data collection process.
  • Empower local commanders to use DoDSER data to produce reports specific to their units/locations.
  • Authorize the VA’s Military Crisis Line staff to access relevant healthcare information.
  • Provide appropriate DoDSER data to the VA to use in their public health surveillance.
  • Update Service policies to specifically encourage participation of Military Criminal Investigative Organizations in the DoDSER submission process.

Management Comments

We received comments from the Under Secretary of Defense for Personnel and Readiness, the Services, and the Military Criminal Investigative Organizations. Management concurred with all 16 recommendations.