Officer Statistic Forms
(for chapter reps only)
Chapter Member filling out form
Head of Agency Name
Best Contact Person in the Agency
Best Contact #
Chapter Family Contact Rep: The chapter member that works with the family.
Chapter Family Contact Date: Date the chapter member reaches out to the family.
Chapter Agency Contact Rep: The chapter member who works with the department.
Chapter Agency Contact Date: Date the chapter member reaches out to the department.
Did the chapter attend the funeral?
PSOB Liaison who will work with the department on filing benefits.
Liaison Officer assigned by the Department (name).
Please check the box below.
Do Not Fill This Out