MassShootingsatVirginiaTech

Addendumtothe
ReportoftheReviewPanel
Presentedto:
GovernorTimothyM.Kaine
CommonwealthofVirginia
MassShootingsatVirginiaTech
Addendumtothe
ReportoftheReviewPanel
Presentedto:
GovernorTimothyM.Kaine
CommonwealthofVirginia
November2009

MassShootingsatVirginiaTech
AddendumtotheReportoftheReviewPanel

Presentedto:

GovernorTimothyM.Kaine
CommonwealthofVirginia

Presentedby:

TriDataDivision,SystemPlanningCorporation
3601WilsonBoulevard
Arlington,VA22201

November2009


INTRODUCTION
On April 16, 2007, Virginia Tech experienced one of the most horrific events in American uni-
versity historya double homicide followed by a mass shooting that left 32 students and fac-
ulty killed, with many others injured, and many more scarred psychologically. Families of the
slain and injured as well as the university community have suffered terribly.
Immediately after the incident Virginia Governor Timothy M. Kaine created a blue ribbon Re-
view Panel, referred to as the Virginia Tech Review Panel, which consisted of nine members
selected for their expertise in the areas that were to be investigated. The Review Panels mis-
sion was to assess the events leading to the shooting and how the incident was handled by the
university and public safety agencies. Mental health services and privacy laws were examined
as well. The Review Panel was to make recommendations that would help college campuses
prevent or mitigate such incidents in the future. The Report of the Review Panel was presented
to the Governor in late August 2007. It is referred to as the Report in this Addendum.
SCOPE OF THIS REPORT: ADDITIONS AND CORRECTIONS
In the two years since the Review Panels report was published, additional information has
been placed in the public record, including Seung Hui Chos case file from the Cook Counseling
Center and a recent report from the Commonwealths Inspector General concerning the Cook
Counseling Centers handling of Chos records. Briefings to the victims families by police and
Virginia Tech officials provided additional details of the events
In light of the new information presented to the families, and other information they found in
the April 16 archive, several family members requested that additions and corrections be made
to the Report. Some families had personal knowledge of the events that were not previously
shared. Some families requested new interpretations of certain findings or revisions to some of
the Review Panels recommendations in light of the new information. Virginia Tech officials
also submitted comments requesting some corrections.
Governor Kaine asked the victims families and Virginia Tech to submit any corrections or ad-
ditions they thought important by the end of August, 2009. The time was extended into Sep-
tember after discovery of Chos missing Cook Counseling Center records.
This Addendum responds to the comments and questions received from the families and Vir-
ginia Tech by correcting facts in the original report, including the timeline, and by adding addi-
tional information about the events leading to the incidents, the response to the incidents, and
the aftermath of April 16. The Addendum also includes corrections to names and titles of peo-
ple cited in the Report or the list of interviewees. The Addendum does not address opinions or
value judgments that were raised, but provides some additional background information that
might help address the concerns raised.
ADDENDUM PROCESS
Governor Kaine engaged the TriData staff that supported the Review Panel to review the addi-
tional information and the questions and comments about the Report. TriData was familiar
with the research and details of the Report, the sources, and the deliberations behind the Re-
ports original findings and recommendations. All comments received by the Governors Office
were forwarded to TriData for review.
INTRODUCTION

The focus of this Addendum is on correcting and adding to the pertinent facts. Many of the
families as well as Virginia Tech submitted corrections or comments and added detailed refer-
ences to documents now in the public record. After completing an initial review of the com-
ments from all parties, TriData submitted a number of questions to Virginia Tech and also in-
terviewed several family members for clarification of their comments, and to cross-check in-
formation and corroborate facts.
There are conflicting opinions on whether the Review Panel should have treated certain issues
differently, reached stronger or different conclusions, placed blame on certain individuals, or
interviewed additional people. The new and additional information has tended to reinforce the
Review Panels original findings and recommendations. In several instances, emphasis was
added to findings where strongly supported by the facts. While some of the findings have been
modified slightly and one added, none of the new information merited changes to any of the
recommendations in the original Report.
A number of questions and corrections were raised about the timeline in the Report. The time-
line was intended to provide an overview of the most important markers in the sequence of
events to assist readers as a reference as they went through the details in the text. The Review
Panel chose not to include many details in the timeline that were later discussed in the text.
This Addendum contains an expanded timeline with virtually all of the additions suggested by
the families.
SCOPE OF ORIGINAL REVIEW PANEL REPORT
As described in the Review Panels Report, Governor Kaines executive order directed the Re-
view Panel to accomplish the following:
1. Conduct a review of how Seung Hui Cho committed these 32 murders and multiple ad-
ditional woundings, including without limitation how he obtained his firearms and am-
munition, and to learn what can be learned about what caused him to commit these acts
of violence.
2. Conduct a review of Seung Hui Cho's psychological condition and behavioral issues
prior to and at the time of the shootings, what behavioral aberrations or potential warn-
ing signs were observed by students, faculty and/or staff at Westfield High School and
Virginia Tech. This inquiry should include the response taken by Virginia Tech and oth-
ers to note psychological and behavioral issues, Seung Hui Cho's interaction with the
mental health delivery system, including without limitation judicial intervention, access
to services, and communication between the mental health services system and Virginia
Tech. It should also include a review of educational, medical, and judicial records docu-
menting his condition, the services rendered to him, and his commitment hearing.
3. Conduct a review of the timeline of events from the time that Seung Hui Cho entered
West Ambler Johnston Dormitory until his death in Norris Hall. Such review shall in-
clude an assessment of the response to the first murders and efforts to stop the Norris
Hall murders once they began.
4. Conduct a review of the response of the Commonwealth, all of its agencies, and rele-
vant local and private providers following the death of Seung Hui Cho for the purpose of
providing recommendations for the improvement of the Commonwealth's response in
similar emergency situations. Such review shall include an assessment of the emer-
gency medical response provided for the injured and wounded, the conduct of post-
INTRODUCTION

mortem examinations and release of remains, on-campus actions following the tragedy,
and the services and counseling offered to the victims, the victims' families, and those
affected by the incident. In so doing, the Review Panel shall to the extent required by
federal or state law: (i) protect the confidentiality of any individual's or family member's
personal or health information; and (ii) make public or publish information and findings
only in summary or aggregate form without identifying personal or health information
related to any individual or family member unless authorization is obtained from an in-
dividual or family member that specifically permits the Review Panel to disclose that
person's personal or health information.
5. Conduct other inquiries as may be appropriate in the Review Panel's discretion other-
wise consistent with its mission and authority as provided herein.
6. Based on these inquiries, make recommendations on appropriate measures that can be
taken to improve the laws, policies, procedures, systems and institutions of the Com-
monwealth and the operation of public safety agencies, medical facilities, local agencies,
private providers, universities, and mental health services delivery system.
In summary, the Review Panel was tasked to review the events, assess actions taken and not
taken, identify lessons learned, and propose alternatives for the future. Included a review of
Chos history and interaction with the mental health and legal systems and of his gun pur-
chases. The Review Panel was also asked to review the emergency response by all parties (law
enforcement officials, university officials, medical responders and hospital care providers, and
the Medical Examiner). Finally, the Review Panel reviewed the aftermaththe universitys
approach to helping families, survivors, students, and staff as they dealt with the mental
trauma and the approach to helping the university heal itself and function again.
REVIEW PANEL AND STAFF
The Review Panel consisted of nine highly distinguished members from a variety of relevant
backgrounds. Members included a former Governor and Secretary of the U.S. Department of
Homeland Security, a judge, a psychiatrist, a professor of emergency medicine, a former FBI
official who established the FBIs Center for the Analysis of Violent Crime, a former head of the
Virginia State Police, a specialist in university administration, and a specialist in assisting
families of crime victims. The Review Panel members volunteered their time for the four-
month study period.
The Review Panel was supported by staff from the TriData Division, System Planning Corpo-
ration of Arlington, Virginia. SPC/TriData specializes in public safety consulting and research,
and had undertaken over 50 studies of major disasters to identify the lessons learned. One of
those studies reported on the lessons learned from the Columbine High School shootings. These
studies were directed by the two TriData managers, Philip Schaenman and Hollis Stambaugh,
who served as the Review Panel staff director and deputy director respectively. TriData also
completed a review for FEMA of the Northern Illinois University mass shooting and authored
this Addendum.
REVIEW PANEL PROCESS AND CONSTRAINTS
Among questions received from the victims families was a request for additional information
about how the Review Panel approached the investigation into the shooting and arrived at
their conclusions, and why certain information was or was not included. Thus, it may be useful
to review the process and the constraints within which the Review Panel worked.
INTRODUCTION

Time Constraints Governor Kaine directed the Review Panel to complete its review of the
Virginia Tech shootings before classes resumed the next semester. This meant that the Report
had to be published by late August 2007, four months after starting. (Elements of the review
started the week immediately following the shooting) The Governor felt it was important to
identify any campus safeguards or executive orders needed before students returned to classes
at Virginia Tech and other schools across the state. It also was important to identify any
changes needed in state legislation with adequate time before the next session of the state leg-
islature. For the families, the Virginia Tech community, and general public, it was important
to produce information as soon as possible on the events of April 16. .
The Review Panel would have liked to have had more time to interview additional people and
to delve further into certain details. However, all understood the importance of getting the
main facts and the big picture correct and out to the public as soon as possible. The Review
Panel used its best judgment on what to cover in the available time in light of the many issues
that were found across many disciplines. As noted above, additional information has become
available since the Report was released. The victims families and Virginia Tech have closely
evaluated the Report in light of the new information and have submitted comments to the Gov-
ernor. These have been thoroughly studied and this Addendum is the product of that work.
While some details are added and some corrected, all the original recommendations remain
valid.
Authority The Review Panel benefited from the Governors authority to collect information
but it did not have subpoena power. State and local police and the FBI provided briefings to the
Review Panel, but the Panel did not have access to the police investigation files. The police
subsequently provided a briefing to the victims families and that information has been in-
cluded in this Addendum.)
Breadth of Interviews In the course of carrying out the Governors directive, the Review
Panel interviewed over 200 individuals, heard presentations from many experts, and listened
to comments from the victims families and the general public at four public hearings held
throughout the state. In addition, thousands of other people sent information, opinions, and
suggestions to a special website established for that purpose.
The interviewees included many faculty, students, injured victims, victims families, law en-
forcement personnel, emergency medical service providers, hospital emergency room personnel,
personnel from the Office of the Medical Examiner and the Office of Victim Services, Virginia
Tech officials, the Virginia Commissioner of Mental Health and personnel from the Virginia
Attorney Generals office. Review Panel members also interviewed Chos family and various
health practitioners who had treated him as well as individuals from his high school, including
his high school guidance counselor.
Four public hearings were held to help gather information and views from selected key indi-
viduals who were close to the events. The Review Panel invited experts in various relevant ar-
eas such as university counseling, police procedures, firearm regulations, and mental health to
make presentations. Time for public comment was provided at the close of each meeting. Vic-
tims families were present throughout the hearings.
Discretion on Details Included In addition to interviews, presentations of experts and
public hearings, the Review Panel examined and discussed over 1,000 pages of documents. The
Review Panel felt it was neither possible nor desirable to publish every fact collected and the
Review Panel used its discretion in determining the most relevant information to include in the
Report. The Review Panel began by including details of Chos personal history and the actions
INTRODUCTION

taken and decisions made by Virginia Tech and law enforcement on April 16 and then con-
cluded with its findings of what improvements should be made. The Review Panel wanted to
avoid obfuscating the major findings in a cloud of lesser important or repetitive details, focus-
ing on the findings and recommendations that were key to improving campus safety. For ex-
ample, Cho had been a student in over 35 different classes and had written some disturbing
material for several English Department faculty members, but only a representative few of his
professors were mentioned and only a few of his papers were cited as examples in the Report.
The Review Panel held several 10 and 12-hour Review Panel work sessions in which Review
Panel members painstakingly evaluated and discussed the assembled information and drafted
recommendations supported by the research.
Independence The Review Panel operated independently from both Virginia Tech and the
Office of the Governor, though numerous Virginia Tech and Commonwealth employees were
interviewed during the review. The Reports findings and recommendations were solely those of
the Review Panel.
To preserve the Reports objectivity, neither Virginia Tech nor the families of the victims were
permitted to comment on drafts of the Report before publication. Families of victims, however,
were briefed on the major findings and the nature of the research during the review process.
ORGANIZATION OF THIS ADDENDUM
Following this introduction are all sections of the original Report and Appendix B. This Adden-
dum presents additions and corrections at the end of each chapter. The additions and correc-
tions are organized by page number of the Report to which the issue was directed. Subject
headings and some context are provided to make the corrections self-standing without need to
reference the text. A revised timeline is included with additional details and corrections to the
original timeline.
A revised interviewee list (Appendix B in the original Report) indicates corrections to names
and positions, and some personal preferences expressed to us from some interviewees of how
they wished their names to be listed. Some other desired changes to names and descriptions
are included in the revised Dedication section.
Specific questions or comments have not been attributed to individuals in order to preserve
confidentiality. All comments and concerns submitted to the Governors office by families and
Virginia Tech were reviewed and addressed. In some cases extensive research failed to sub-
stantiate a suggested change, but most of the factual comments resulted in changes or clarifi-
cations. Comments appear immediately following the corrections and additions on other issues
raised that had incorrect factual basis or that missed some information in the Report.
The original Report continues to stand as it was written by the Review Panel. The Review
Panel worked hard on crafting the language of its Report and on reaching consensus on its
findings and recommendations. The primary intent of this Addendum is to correct the factual
record, both for future understanding of the terrible events of April 16, 2007, and to honor and
respect those who died or suffered from the attacks.
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iii
Contents
INTRODUCTION
DEDICATION
FOREWORD................................................................................................................................. vii
ACKNOWLEDGEMENTS............................................................................................................ ix
TriData, a Division of System Planning Corporation.................................................................ix
Skadden, Arps, Slate, Meagher & Flom LLP...............................................................................9
SUMMARY OF KEY FINDINGS..................................................................................................1
Chapter I. BACKGROUND AND SCOPE ..................................................................................5
Scope...............................................................................................................................................5
Methodology ...................................................................................................................................6
Findings and Recommendations .................................................................................................10
Chapter II. UNIVERSITY SETTING AND SECURITY.........................................................11
University Setting........................................................................................................................11
Campus Police and Other Local Law Enforcement ...................................................................11
Building Security .........................................................................................................................13
Campus Alerting Systems ...........................................................................................................14
Emergency Response Plan...........................................................................................................16
Key Findings ................................................................................................................................17
Recommendations ........................................................................................................................19
Chapter III. REVISED TIMELINE OF EVENTS....................................................................21
Pre-Incidents: Chos History .......................................................................................................21
The Incidents................................................................................................................................26
Post-Incident ................................................................................................................................32
Chapter IV. MENTAL HEALTH HISTORY OF SEUNG HUI CHO ....................................31
Early Years...................................................................................................................................31
Elementary School in Virginia....................................................................................................33
Middle School Years.....................................................................................................................34
High School Years........................................................................................................................36
College Years................................................................................................................................40
Chos Hospitalization and Commitment Proceedings................................................................46
After Hospitalization ...................................................................................................................49
Missing the Red Flags .................................................................................................................52
Key Findings Chos College Years to April 15, 2007 T ...........................................................52
Recommendations ........................................................................................................................53
Time Constraints for Evaluation and Hearing ..........................................................................55
Standard for Involuntary Commitment......................................................................................56
Psychiatric Information...............................................................................................................56
Certification of Orders to the Central Criminal Records Exchange ........................................59
Key Findings ................................................................................................................................60
Recommendations ........................................................................................................................60

iv
Chapter V. INFORMATION PRIVACY LAWS........................................................................63
Law Enforcement Records........................................................................................................... 63
Judicial Records........................................................................................................................... 64
Medical Information .................................................................................................................... 65
Educational Records .................................................................................................................... 65
Government Data Collection and Dissemination Practices Act................................................ 67
Key Findings ................................................................................................................................ 68
Recommendations........................................................................................................................ 68
Chapter VI. GUN PURCHASE AND CAMPUS POLICIES ..................................................71
Firearms Purchases..................................................................................................................... 71
Ammunition purchases................................................................................................................ 74
Guns on Campus.......................................................................................................................... 74
Key Findings ................................................................................................................................ 75
Recommendations........................................................................................................................ 76
Chapter VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON.................................77
Approach and Attack................................................................................................................... 77
Premature Conclusion? ............................................................................................................... 79
Delayed Alert to University Community................................................................................... 80
Decision Not to Cancel Classes or Lock down............................................................................ 82
Continuing Events....................................................................................................................... 84
Motivation for First Killings?...................................................................................................... 86
Key Findings ................................................................................................................................ 86
Recommendations........................................................................................................................ 87
Chapter VIII. MASS MURDER AT NORRIS HALL ..............................................................89
The Shootings............................................................................................................................... 90
Defensive Actions......................................................................................................................... 92
Police Response............................................................................................................................ 94
University Messages.................................................................................................................... 95
Other Actions on the Second and Third Floors .......................................................................... 97
Action on the First Floor ............................................................................................................. 98
The Toll ........................................................................................................................................ 98
Key Findings ................................................................................................................................ 98
Recommendations........................................................................................................................ 99
Chapter IX. EMERGENCY MEDICAL SERVICES RESPONSE.......................................101
West Ambler Johnston Initial Response .................................................................................. 101
Norris Hall Initial Response ..................................................................................................... 102
EMS Incident Command System.............................................................................................. 103
Hospital Response...................................................................................................................... 110
Emergency Management...........................................................................................................116
Key Findings .............................................................................................................................. 121
Recommendations...................................................................................................................... 122
Chapter X. OFFICE OF THE CHIEF MEDICAL EXAMINER...........................................123
Legal Mandates and Standards of Care ................................................................................... 123
Death Notification ..................................................................................................................... 124
Events......................................................................................................................................... 124

v
Issues..........................................................................................................................................127
Key Findings ..............................................................................................................................131
Recommendations ......................................................................................................................132
A Final Word..............................................................................................................................133
Chapter XI. IMMEDIATE AFTERMATH AND THE LONG ROAD TO HEALING........135
First Hours .................................................................................................................................136
Actions by Virginia Tech ...........................................................................................................136
Meetings, Visits, and Other Communications with Families and with the Injured..............142
Ceremonies and memorial events.............................................................................................144
Volunteers and Onlookers .........................................................................................................144
Communications with the Medical Examiners Office.............................................................145
Department of Public Safety .....................................................................................................145
Key Findings ..............................................................................................................................145
Recommendations ......................................................................................................................146
Appendix B. INDIVIDUALS INTERVIEWED BY RESEARCH PANEL......................... B1

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DEDICATION
The Virginia Tech Review Panel invited the families of the victims to lend their words as a
dedication of this report. The panel is honored to share their words of love, remembrance, and
strength.

We dedicate this report not solely to those who lost their lives at Virginia Tech on April 16,
2007, and to those physically and/or psychologically wounded on that dreadful morning, but
also to every student, teacher, and institution of learning, that we may all safely fulfill
our goals of learning, educating, and enriching humanity's stores of knowledge: the very arts
and sciences that ennoble us.*
"Love does not die, people do. So when all that is left of me is love
Give me away" J ohn Wayne Schlatter
"This is the beginning of a new day. You have been given this day to use as you will. You can
waste it or use it for good. What you do today is important because you are exchanging a day of
your life for it. When tomorrow comes, this day will be gone forever; in its place is something that
you have left behindlet it be something good." Anonymous
"We should consider every day lost on which we have not danced at least once. And we
should call every truth false which was not accompanied by at least one laugh."
Friedrich Nietzsche
"Unable are the loved to die, for Love is Immortality." Emily Dickinson

32 candles burning bright for all to see,
Lifting up the world for peace and harmony,
Those of us who are drawn to the lights,
enduringly embedded in our mind, indelibly
ingrained on our heart, forever identifying our spirit,
We call out your name:
Erin, Ryan, Emily, Reema, Daniel, Matthew, Kevin, Brian, Jarrett, Austin, Henry, Liviu, Nicole, Julia,
Lauren, Partahi, Jamie, Jeremy, Rachel, Caitlin, Maxine, Jocelyne, Leslie, Juan, Daniel, Ross, G.V.,
Mary, Matthew, Minal, Michael, Waleed,
and,
hold these truths ever so tight,
your lives have great meaning, your lives have great power, your lives will never be
forgotten, YOU will always be remembered,
never and always
Pat Craig
*Neither this dedication nor the use herein of the victims' photos or bios represents an en-
dorsement of the report by the victims' families.
DEDICATION


Ross A. Alameddine
Hometown: Saugus, Massachusetts
Sophomore, University Studies
Student since fall 2005
Posthumous degree:
Bachelor of Arts, English and Foreign
Languages/French


Ryan Christopher Clark
Hometown: Martinez, Georgia
Senior, Psychology
Student since fall 2002
Posthumous degrees:
Bachelor of Science, Biological Sciences
Bachelor of Arts, English
Bachelor of Science, Psychology


Matthew Gregory Gwaltney
Hometown: Chesterfield, Virginia
Masters student, Environmental Engi-
neering
Student since fall 2001
Posthumous degree:
Master of Science, Environmental Engi-
neering

Christopher James Bishop
Residence in Blacksburg
Instructor, Foreign Languages
Joined Virginia Tech on
August 10, 2005


Austin Michelle Cloyd
Hometown: Blacksburg, Virginia
Sophomore, Honors Program, Interna-
tional Studies
Student since fall 2006
Posthumous degrees:
Bachelor of Arts, Foreign Lan-
guages/French
Bachelor of Arts, International Studies


Caitlin Millar Hammaren
Hometown: Westtown, New York
Sophomore, International Studies
Student since fall 2005
Posthumous degree:
Bachelor of Arts, International Studies

Brian Roy Bluhm
Hometown: Cedar Rapids, Iowa
Masters student, Civil Engineering
Student since fall 2000
Posthumous degree:
Master of Science, Civil Engineering


Kevin P. Granata
Residence in Blacksburg
Professor, Engineering Science and Mechan-
ics
Joined Virginia Tech on
January 10, 2003




Jeremy Michael Herbstritt
Hometown: Blacksburg, Virginia
Masters student, Civil Engineering
Student since fall 2006
Posthumous degree:
Master of Science, Civil Engineering
DEDICATION


Rachael Elizabeth Hill
Hometown: Glen Allen, Virginia
Freshman, University Studies
Student since fall 2006
Posthumous degree:
Bachelor of Science, Biological Sciences



Jarrett Lee Lane
Hometown: Narrows, Virginia
Senior, Civil Engineering
Student since fall 2003
Posthumous degree:
Bachelor of Science, Civil Engineering



Liviu Librescu
Residence in Blacksburg
Professor, Engineering Science and
Mechanics
Joined Virginia Tech on
September 1, 1985

Emily Jane Hilscher
Hometown: Woodville, Virginia
Freshman, Animal and Poultry Sciences
Student since fall 2006
Posthumous degree:
Bachelor of Science, Animal and Poultry
Sciences



Matthew Joseph La Porte
Hometown: Dumont, New Jersey
Sophomore, University Studies
Student since fall 2005
Posthumous degree:
Bachelor of Arts, Political Science



G. V. Loganathan
Residence in Blacksburg
Professor, Civil and Environmental
Engineering
Joined Virginia Tech on
December 16, 1981

Partahi Mamora Halomoan
Lumbantoruan
Hometown: Blacksburg, Virginia (originally
from Indonesia)
Ph.D. student, Civil Engineering
Student since fall 2003
Posthumous degree:
Doctor of Philosophy, Civil Engineering


Henry J. Lee
Hometown: Roanoke, Virginia
Sophomore, Computer Engineering
Student since fall 2006
Posthumous degree:
Bachelor of Science, Computer Engineering


Lauren Ashley McCain
Hometown: Hampton, Virginia
Freshman, International Studies
Student since fall 2006
Posthumous degree:
Bachelor of Arts, International Studies
DEDICATION


Jocelyne Couture-Nowak
Residence in Blacksburg
Adjunct Professor, Foreign Languages
Joined Virginia Tech on
August 10, 2001





Minal Hiralal Panchal
Hometown: Mumbai, India
Masters student, Architecture
Student since fall 2006
Posthumous degree:
Master of Science, Architecture



Michael Steven Pohle, Jr.
Hometown: Flemington, New Jersey
Senior, Biological Sciences
Student since fall 2002
Posthumous degree:
Bachelor of Science, Biological Sciences

Daniel Patrick ONeil
Hometown: Lincoln, Rhode Island
Masters student, Environmental Engi-
neering
Student since fall 2006
Posthumous degree:
Master of Science, Environmental Engi-
neering


Daniel Alejandro Perez
Hometown: Woodbridge, Virginia
Sophomore, International Studies
Student since summer 2006
Posthumous degree:
Bachelor of Arts, International Studies


Julia Kathleen Pryde
Hometown: Blacksburg, Virginia
Masters student, Biological Systems
Engineering
Student since fall 2001
Posthumous degree:
Master of Science, Biological Systems
Engineering

Juan Ramon Ortiz-Ortiz
Hometown: Blacksburg, Virginia
Masters student, Civil Engineering
Student since fall 2006
Posthumous degree:
Master of Science, Civil Engineering




Erin Nicole Peterson
Hometown: Centreville, Virginia
Freshman, International Studies
Student since fall 2006
Posthumous degree:
Bachelor of Arts, International Studies


Mary Karen Read
Hometown: Annandale, Virginia
Freshman, Interdisciplinary Studies
Student since fall 2006
Posthumous degree:
Bachelor of Arts, Interdisciplinary Studies
DEDICATION


Reema Joseph Samaha
Hometown: Centreville, Virginia
Freshman, University Studies
Student since fall 2006
Posthumous degrees:
Bachelor of Arts, International Studies
Bachelor of Arts, Public and Urban Affairs


Maxine Shelly Turner
Hometown: Vienna, Virginia
Senior, Honors Program, Chemical
Engineering
Student since fall 2003
Posthumous degree: Bachelor of Science,
Chemical Engineering


Waleed Mohamed Shaalan
Hometown: Blacksburg, Virginia (origi-
nally from Egypt)
Ph.D. student, Civil Engineering
Student since fall 2006
Posthumous degree:
Doctor of Philosophy, Civil Engineering


Nicole Regina White
Hometown: Smithfield, Virginia
Sophomore, International Studies
Student since fall 2004
Posthumous degree:
Bachelor of Arts, International Studies


Leslie Geraldine Sherman
Hometown: Springfield, Virginia
Junior, Honors Program, History
Student since fall 2005
Posthumous degrees:
Bachelor of Arts, History
Bachelor of Arts, International Studies


ADDITIONS AND CORRECTIONS
Two of the above write-ups on the victims have had changes made as requested by
their families.

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vii
FOREWORD
From Timothy M. Kaine
Governor, Commonwealth Of Virginia
On April 16, 2007, a tragic chapter was added to Virginias history when a disturbed
young man at Virginia Tech took the lives of 32 students and faculty, wounded many others,
and killed himself. In the midst of unspeakable grief, the Virginia Tech community stood to-
gether, with tremendous support from friends in all corners of the world, and made us proud to
be Virginians.
Over time, the tragedy has been felt by all it touched, most deeply by the families of
those who were killed and by the wounded survivors and their families. The impact has been
felt as well by those who witnessed or responded to the shooting, the broad Virginia Tech com-
munity, and those who are near to Blacksburg geographically or in spirit.
In the days immediately after the shooting, I knew it was critical to seek answers to the
many questions that would arise from the tragedy. I also felt that the questions should be ad-
dressed by people who possessed both the expertise and autonomy necessary to do a compre-
hensive review. Accordingly, I announced on April 19 the formation of the Virginia Tech Re-
view Panel to perform a review independent of the Commonwealths own efforts to respond to
the terrible events of April 16. The Panel members readily agreed to devote time, expertise,
and emotional energy to this difficult task.
Those who agreed to serve were:
Panel Chair Col. Gerald Massengill, a retired Virginia State Police Superintendent who
led the Commonwealths law enforcement response to the September 11, 2001, attack on
the Pentagon and the sniper attacks that affected the Commonwealth in 2002.
Panel Vice Chair Dr. Marcus L. Martin, Professor of Emergency Medicine, Assistant
Dean of the School of Medicine and Associate Vice President for Diversity and Equity at
the University of Virginia.
Gordon Davies, former Director of the State Council of Higher Education for Virginia
(19771997) and President of the Kentucky Council on Postsecondary Education (1998
2002).
Dr. Roger L. Depue, a 20-year veteran of the FBI and the founder, past president and
CEO of The Academy Group, Inc., a forensic behavioral sciences services company pro-
viding consultation, research, and investigation of aberrant and violent behavioral prob-
lems.
FOREWORD FROM GOVERNOR KAINE
viii
Carroll Ann Ellis, MS, Director of the Fairfax County Police Departments Victim Ser-
vices Division, a faculty member at the National Victim Academy, and a member of the
American Society of Victimology.
The Honorable Tom Ridge, former Governor of Pennsylvania (19952001) and Member
of the U.S. House of Representatives (19831995) who was also the first U.S. Secretary
of Homeland Security (20032005).
Dr. Aradhana A. Bela Sood, Professor of Psychiatry and Pediatrics, Chair of Child and
Adolescent Psychiatry and Medical Director of the Virginia Treatment Center for Chil-
dren at VCU Medical Center.
The Honorable Diane Strickland, former judge of the 23rd Judicial Circuit Court in
Roanoke County (19892003) and co-chair of the Boyd-Graves Conference on issues sur-
rounding involuntary mental commitment.
These nationally recognized individuals brought expertise in many areas, including law
enforcement, security, governmental management, mental health, emergency care, victims
services, the Virginia court system, and higher education.
An assignment of this importance required expert technical assistance and this was
provided by TriData, a division of System Planning Corporation. TriData has worked on nu-
merous reports following disasters and tragedies, including a report on the 1999 shooting at
Columbine High School. Phil Schaenman and Hollis Stambaugh led the TriData team.
The Panel also needed wise and dedicated legal counsel and that counsel was provided
on a pro bono basis by the Washington, D.C., office of the law firm Skadden, Arps, Slate,
Meagher & Flom, L.L.P. The Skadden Arps team was led by partners Richard Brusca and Amy
Sabrin.
The level of personal commitment by the Panel members, staff and counsel throughout
the process was extraordinary. This report is the product of intense work and deliberation and
the Commonwealth stands indebted to all who worked on it.
The magnitude of the losses suffered by victims and their families, the Virginia Tech
community, and our Commonwealth is immeasurable. We have lost people of great character
and intelligence who came to Virginia Tech from around our state, our nation and the world.
While we can never know the full extent of the contributions they would have made had their
lives not been cut short, we can say with confidence that they had already given much of them-
selves toward advancing knowledge and helping others.
We must now challenge ourselves to study this report carefully and make changes that
will reduce the risk of future violence on our campuses. If we act in that way, we will honor the
lives and sacrifices of all who suffered on that terrible day and advance the notion of service
that is Virginia Techs fundamental mission.
FOREWORD FROM GOVERNOR KAINE
viii - A
ADDITIONS AND CORRECTIONS
(No changes from original report.)
(This page intentionally left blank.)

ix
ACKNOWLEDGEMENTS
he Virginia Tech Review Panel thanks the many persons who contributed to gathering in-
formation, provided facilities at which the panel held four public meetings around the
state, and helped prepare this report. The administration and staff of Virginia Tech, George
Mason University, and the University of Virginia hosted public meetings at which speakers
presented background information and family members of the victims addressed the panel. The
University of Virginia also provided facilities for the panel to meet in three sessions to discuss
confidential material related to this report.
The panel is grateful to more than 200 persons who were interviewed or who participated in
discussion groups. They are identified in Appendix B.
Finally, the panel is grateful for staff support and legal advice provided by TriData, a Division
of System Planning Corporation, and Skadden, Arps, Slate, Meagher & Flom LLP.
TRIDATA, A DIVISION OF SYSTEM PLANNING CORPORATION
Philip Schaenman, panel staff
director
Hollis Stambaugh, panel staff
deputy director
Jim Kudla, panel public informa-
tion officer
Dr. Harold Cohen
Darryl Sensenig
Paul Flippin
Teresa Copping
Maria Argabright
Shania Flagg
Lucius Lamar III
Rachel Mershon
Jim Gray
SKADDEN, ARPS, SLATE, MEAGHER & FLOM LLP
Richard Brusca
Amy Sabrin
Michael Tierney
Michael Kelly
Ian Erickson

Brad Marcus
Cory Black, Summer Associate
Ray McKenzie, Summer
Associate
Colin Ram, Summer Associate

ADDITIONS AND CORRECTIONS
(No changes from original report.)

T
(This page intentionally left blank.)

1
SUMMARY OF KEY FINDINGS
n April 16, 2007, Seung Hui Cho, an angry and disturbed student, shot to death 32 stu-
dents and faculty of Virginia Tech, wounded 17 more, and then killed himself.
The incident horrified not only Virginians, but people across the United States and throughout
the world.
Tim Kaine, Governor of the Commonwealth of Virginia, immediately appointed a panel to re-
view the events leading up to this tragedy; the handling of the incidents by public safety offi-
cials, emergency services providers, and the university; and the services subsequently provided
to families, survivors, care-givers, and the community.
The Virginia Tech Review Panel reviewed several separate but related issues in assessing
events leading to the mass shootings and their aftermath:
The life and mental health history of Seung Hui Cho, from early childhood until the
weeks before April 16.
Federal and state laws concerning the privacy of health and education records.
Cho's purchase of guns and related gun control issues.
The double homicide at West Ambler Johnston (WAJ) residence hall and the mass
shootings at Norris Hall, including the responses of Virginia Tech leadership and the
actions of law enforcement officers and emergency responders.
Emergency medical care immediately following the shootings, both onsite at Virginia
Tech and in cooperating hospitals.
The work of the Office of the Chief Medical Examiner of Virginia.
The services provided for surviving victims of the shootings and others injured, the
families and loved ones of those killed and injured, members of the university commu-
nity, and caregivers.
The panel conducted over 200 interviews and reviewed thousands of pages of records, and
reports the following major findings:
1. Cho exhibited signs of mental health problems during his childhood. His middle and
high schools responded well to these signs and, with his parents' involvement, provided
services to address his issues. He also received private psychiatric treatment and coun-
seling for selective mutism and depression.
In 1999, after the Columbine shootings, Chos middle school teachers observed suicidal
and homicidal ideations in his writings and recommended psychiatric counseling, which
he received. It was at this point that he received medication for a short time. Although
Chos parents were aware that he was troubled at this time, they state they did not spe-
cifically know that he thought about homicide shortly after the 1999 Columbine school
shootings.
O
SUMMARY OF KEY FINDINGS
2
2. During Cho's junior year at Virginia Tech, numerous incidents occurred that were clear
warnings of mental instability. Although various individuals and departments within
the university knew about each of these incidents, the university did not intervene
effectively. No one knew all the information and no one connected all the dots.
3. University officials in the office of Judicial Affairs, Cook Counseling Center, campus
police, the Dean of Students, and others explained their failures to communicate with
one another or with Chos parents by noting their belief that such communications are
prohibited by the federal laws governing the privacy of health and education records. In
reality, federal laws and their state counterparts afford ample leeway to share informa-
tion in potentially dangerous situations.
4. The Cook Counseling Center and the universitys Care Team failed to provide needed
support and services to Cho during a period in late 2005 and early 2006. The system
failed for lack of resources, incorrect interpretation of privacy laws, and passivity.
Records of Chos minimal treatment at Virginia Techs Cook Counseling Center are
missing.
5. Virginias mental health laws are flawed and services for mental health users are
inadequate. Lack of sufficient resources results in gaps in the mental health system
including short term crisis stabilization and comprehensive outpatient services. The
involuntary commitment process is challenged by unrealistic time constraints, lack of
critical psychiatric data and collateral information, and barriers (perceived or real) to
open communications among key professionals.
6. There is widespread confusion about what federal and state privacy laws allow. Also,
the federal laws governing records of health care provided in educational settings are
not entirely compatible with those governing other health records.
7. Cho purchased two guns in violation of federal law. The fact that in 2005 Cho had been
judged to be a danger to himself and ordered to outpatient treatment made him ineligi-
ble to purchase a gun under federal law.
8. Virginia is one of only 22 states that report any information about mental health to a
federal database used to conduct background checks on would-be gun purchasers. But
Virginia law did not clearly require that persons such as Chowho had been ordered
into out-patient treatment but not committed to an institutionbe reported to the data-
base. Governor Kaines executive order to report all persons involuntarily committed for
outpatient treatment has temporarily addressed this ambiguity in state law. But a
change is needed in the Code of Virginia as well.
9. Some Virginia colleges and universities are uncertain about what they are permitted to
do regarding the possession of firearms on campus.
10. On April 16, 2007, the Virginia Tech and Blacksburg police departments responded
quickly to the report of shootings at West Ambler Johnston residence hall, as did the
Virginia Tech and Blacksburg rescue squads. Their responses were well coordinated.
11. The Virginia Tech police may have erred in prematurely concluding that their initial
lead in the double homicide was a good one, or at least in conveying that impression to
university officials while continuing their investigation. They did not take sufficient
action to deal with what might happen if the initial lead proved erroneous. The police
SUMMARY OF KEY FINDINGS
3
reported to the university emergency Policy Group that the "person of interest" probably
was no longer on campus.
12. The VTPD erred in not requesting that the Policy Group issue a campus-wide notifica-
tion that two persons had been killed and that all students and staff should be cautious
and alert.
13. Senior university administrators, acting as the emergency Policy Group, failed to issue
an all-campus notification about the WAJ killings until almost 2 hours had elapsed.
University practice may have conflicted with written policies.
14. The presence of large numbers of police at WAJ led to a rapid response to the first 9-1-1
call that shooting had begun at Norris Hall.
15. Chos motives for the WAJ or Norris Hall shootings are unknown to the police or the
panel. Cho's writings and videotaped pronouncements do not explain why he struck
when and where he did.
16. The police response at Norris Hall was prompt and effective, as was triage and evacua-
tion of the wounded. Evacuation of others in the building could have been implemented
with more care.
17. Emergency medical care immediately following the shootings was provided very effec-
tively and timely both onsite and at the hospitals, although providers from different
agencies had some difficulty communicating with one another. Communication of accu-
rate information to hospitals standing by to receive the wounded and injured was
somewhat deficient early on. An emergency operations center at Virginia Tech could
have improved communications.
18. The Office of the Chief Medical Examiner properly discharged the technical aspects of
its responsibility (primarily autopsies and identification of the deceased). Communica-
tion with families was poorly handled.
19. State systems for rapidly deploying trained professional staff to help families get infor-
mation, crisis intervention, and referrals to a wide range of resources did not work.
20. The university established a family assistance center at The Inn at Virginia Tech, but it
fell short in helping families and others for two reasons: lack of leadership and lack of
coordination among service providers. University volunteers stepped in but were not
trained or able to answer many questions and guide families to the resources they
needed.
21. In order to advance public safety and meet public needs, Virginias colleges and univer-
sities need to work together as a coordinated system of state-supported institutions.
As reflected in the body of the report, the panel has made more than 70 recommendations di-
rected to colleges, universities, mental health providers, law enforcement officials, emergency
service providers, law makers, and other public officials in Virginia and elsewhere.

SUMMARY OF KEY FINDINGS
4
ADDITIONS AND CORRECTIONS
Missing Records: p. 2, Finding #4, Addition Chos records that were missing from the
Cook Counseling Center in 2007 subsequently were found in the summer of 2009. They had
been inadvertently removed by the then Director of the Counseling Center, Dr. Robert Miller,
who said he found them at his home while looking for records in response to the discovery proc-
ess related to legal proceedings.
Guns on Campus: p. 2, Finding #9, Addition Virginia Tech had a no guns on campus
policy in place in 2007.
Conflicting Policy: p. 3, Finding #13, Correction Virginia Tech had two different emer-
gency notification policies in effect on April 16, 2005. Their actions followed one of the policies
but conflicted with the other regarding police authority to send out an alert. The mechanics of
the alert system precluded police from sending an alert directly.
Timely Notification of Families of Double Homicide Victims: p. 3, New Finding #22
Emily Hilscher (one of the victims of the double homicide at West Ambler Johnston) survived
for three hours and was transported from the scene to one hospital and later transferred to an-
other. Despite the fact that her identity was known neither Virginia Tech nor law enforcement
nor hospital representatives informed her parents that she had been shot and seriously
wounded, or where she had been taken for medical treatment, until after her death.


5
Chapter I.
BACKGROUND AND SCOPE
n April 16, 2007, one student, senior Seung
Hui Cho, murdered 32 and injured 17 stu-
dents and faculty in two related incidents on the
campus of Virginia Polytechnic Institute and
State University (Virginia Tech). Three days
later, Virginia Governor Tim Kaine commis-
sioned a panel of experts to conduct an inde-
pendent, thorough, and objective review of the
tragedy and to make recommendations regarding
improvements to the Commonwealths laws, poli-
cies, procedures, systems and institutions, as
well as those of other governmental entities and
private providers. On June 18, 2007, Governor
Kaine issued Executive Order 53 reaffirming the
establishment of the Virginia Tech Review Panel
and clarifying the panels authority to obtain
documents and information necessary for its
review. (See Executive Order 53 (2007),
Appendix A.)
Each member of the appointed panel had
expertise in areas relevant to its work, including
Virginias mental health system, university
administration, public safety and security, law
enforcement, victim services, emergency medical
services, and the justice system. The panel
members and their qualifications are specified in
the Foreword to this report. The panel was
assisted in its research and logistics by the
TriData Division of System Planning
Corporation (SPC).
In June, the governor appointed the law firm of
Skadden, Arps, Slate, Meagher & Flom, LLP, as
independent legal counsel to the panel. A team of
their lawyers provided their services on a pro
bono basis. Their advice helped enormously as
they identified the authority needed to obtain
key information and guided the panel through
many sensitive legal areas related to obtaining
and protecting information, public access to the
panel and its work, and other issues. Their
advice and counsel were invaluable.
The governor requested a report be submitted in
August 2007. The panel devoted substantial time
and effort from early May to late August to com-
pleting its review and preparing the report. All
panel members served pro bono. The panel rec-
ognizes that some matters may need to be
addressed more fully in later research.
SCOPE
he governors executive order directed the
panel to answer the following questions:
1. Conduct a review of how Seung Hui Cho
committed these 32 murders and multi-
ple additional woundings, including
without limitation how he obtained his
firearms and ammunition, and to learn
what can be learned about what caused
him to commit these acts of violence.
2. Conduct a review of Seung Hui Cho's
psychological condition and behavioral
issues prior to and at the time of the
shootings, what behavioral aberrations
or potential warning signs were observed
by students, faculty and/or staff at West-
field High School and Virginia Tech. This
inquiry should include the response
taken by Virginia Tech and others to
note psychological and behavioral issues,
Seung Hui Cho's interaction with the
mental health delivery system, including
without limitation judicial intervention,
access to services, and communication
between the mental health services sys-
tem and Virginia Tech. It should also
include a review of educational, medical
and judicial records documenting his
O
T
CHAPTER I. BACKGROUND AND SCOPE
6
condition, the services rendered to him,
and his commitment hearing.
3. Conduct a review of the timeline of
events from the time that Seung Hui Cho
entered West Ambler Johnston dormitory
until his death in Norris Hall. Such
review shall include an assessment of the
response to the first murders and efforts
to stop the Norris Hall murders once
they began.
4. Conduct a review of the response of the
Commonwealth, all of its agencies, and
relevant local and private providers
following the death of Seung Hui Cho for
the purpose of providing recommendations
for the improvement of the
Commonwealth's response in similar
emergency situations. Such review shall
include an assessment of the emergency
medical response provided for the injured
and wounded, the conduct of post-mortem
examinations and release of remains, on-
campus actions following the tragedy, and
the services and counseling offered to the
victims, the victims' families, and those
affected by the incident. In so doing, the
panel shall to the extent required by
federal or state law: (i) protect the
confidentiality of any individual's or
family member's personal or health
information; and (ii) make public or
publish information and findings only in
summary or aggregate form without
identifying personal or health information
related to any individual or family
member unless authorization is obtained
from an individual or family member that
specifically permits the panel to disclose
that person's personal or health
information.
5. Conduct other inquiries as may be
appropriate in the panel's discretion
otherwise consistent with its mission and
authority as provided herein.
6. Based on these inquiries, make
recommendations on appropriate
measures that can be taken to improve
the laws, policies, procedures, systems
and institutions of the Commonwealth
and the operation of public safety
agencies, medical facilities, local
agencies, private providers, universities,
and mental health services delivery
system.
In summary, the panel was tasked to review the
events, assess actions taken and not taken,
identify lessons learned, and propose
alternatives for the future. Its assignment
included a review of Chos history and
interaction with the mental health and legal
systems and of his gun purchases. The panel was
also asked to review the emergency response by
all parties (law enforcement officials, university
officials, medical responders and hospital care
providers, and the Medical Examiner). Finally,
the panel reviewed the aftermaththe
universitys approach to helping families,
survivors, students, and staff as they dealt with
the mental trauma and the approach to helping
the university itself heal and function again.
METHODOLOGY
he panel used a variety of research and
investigatory techniques and procedures,
with the goal of conducting its review in a
manner that was as open and transparent as
possible, consistent with protecting individual
privacy where appropriate and the
confidentiality of certain records where required
to do so.
Much of the panels work was done in parallel by
informal subgroups on topics such as mental
health and legal issues, emergency medical
services, law enforcement, and security. The
panel was supplemented by SPC/TriData and
Skadden staff with expertise in these areas.
Throughout the process, panel members
identified documents to be obtained and people
to be interviewed. The list of interview subjects
continued to grow as the review led to new
questions and as people came forth to give
information and insights to the panel.
T
CHAPTER I. BACKGROUND AND SCOPE
7
From the beginning, the concept was to structure
the review according to the broad timeline
pertinent to the incidents: pre-incident (Chos
history and security status of the university); the
two shooting incidents and the emergency
response to them; and the aftermath. This
helped ensure that all issues were covered in a
logical, systematic fashion.
Openness The panels objective was to conduct
the review process as openly as possible while
maintaining confidential aspects of the police
investigation, medical records, court records,
academic records, and information provided in
confidence. The panels work was governed by
the Virginia Freedom of Information Act, and the
requirements of that act were adhered to strictly.
Requests for Documents and
Information An essential aspect of the
review was the cooperation the panel received
from many institutions and individuals,
including the staff of Virginia Tech, Fairfax
County Public School officials and employees, the
families of shooting victims, survivors, the Cho
family, law enforcement agencies, mental health
providers, the Virginia Medical Examiner, and
emergency medical responders, as well as
numerous public agencies and private
individuals who responded to the panels
requests for documents and information.
Notwithstanding some difficulties at the outset,
the Executive Order of June 18, 2007, and the
work of our outside counsel ultimately allowed
the panel to obtain copies of, review, or be briefed
on all records germane to its review. In this
regard, however, a few matters should be noted.
First, as explained more fully in the body of the
report, the universitys Cook Counseling Center
advised the panel that it was missing certain
records related to Cho that would be expected to
be in the centers files.
Second, due to the sensitive nature of portions of
the law enforcement investigatory record and
due to law enforcements concerns about not
setting a precedent with regard to the release of
raw information from investigation files, the
panel received extensive briefings and
summaries from law enforcement officials about
their investigation rather than reviewing those
files directly. These included briefings by campus
police, Blacksburg Police, Montgomery County
Police, Virginia State Police, FBI, and U.S.
Bureau of Alcohol, Tobacco, Firearms and
Explosives (ATF). The first two such briefings
were conducted in private because they included
protected criminal investigation information and
some material that was deemed insensitive to air
in public. Most of the information received in
confidence was subsequently released in public
briefings and through the media. Although the
panel did not have direct access to criminal
investigation files and materials in their
entirety, the panel was able to validate the
information contained in these briefings from the
records it did have access to from other sources
and from discussions with many of the same
witnesses who spoke to the criminal
investigators. The panel believes that it has
obtained an accurate picture of the police
response and investigation.
Finally, with respect to Chos firearms pur-
chases, the Virginia State Police, the ATF, and
the gun dealers each declined to provide the
panel with copies of the applications Cho com-
pleted when he bought his weapons or of other
records relating to any background check that
may have occurred in connection with those pur-
chases. The Virginia State Police, however, did
describe the contents of Chos gun purchase
applications to members of the panel and its
staff.
Virginia Tech Cooperation An essential
aspect of the review was the cooperation of the
Virginia Tech administration and faculty.
Despite their having to deal with extraordinary
problems, pressures, and demands, the
university provided the panel with the records
and information requested, except for a few that
were missing. Some information was delayed
until various privacy issues were resolved, but
ultimately all records that were requested and
still existed were provided. University President
Charles Steger appointed a liaison to the panel,
Lenwood McCoy, a retired senior university
CHAPTER I. BACKGROUND AND SCOPE
8
official. Requests for meetings and information
went to him. He helped identify the right people
to provide the requested information or obtained
the information himself. The panel sometimes
requested to speak to specific individuals, and all
were made available. Many of the exchanges
were monitored by the universitys attorney, who
is a special assistant state attorney general.
Overall, the university was extremely
cooperative with the panel, despite knowing that
the panels duty was to turn a critical eye on
everything it did.
Interviews Many interviews were conducted
by panel members and staff during the course of
this reviewover 200. A list of persons inter-
viewed is included in Appendix B. A few inter-
viewees wanted to remain anonymous and are
not included. Panel members and staff held
numerous private meetings with family members
of victims and with survivors and their family
members.
One group of interviews was to obtain first-hand
information about the incidents from victims and
responders. This included surviving students and
faculty, police, emergency medical personnel and
hospital emergency care providers, and coordina-
tors. The police used hundreds of personnel from
many law enforcement agencies for their investi-
gation, and the panel did not have nor need the
resources to duplicate that effort. Rather, the
panel obtained the benefit of much of the inves-
tigative information from the law enforcement
agencies. Interviews were conducted with survi-
vors, witnesses, and responders to validate the
information received and to expand upon it.
To further evaluate the actions taken by law
enforcement, the university, and emergency
medical services against state and national stan-
dards and norms, panel members and staff also
conducted interviews with leaders in these fields
outside the Virginia Tech community, from else-
where in Virginia and from other states. The
panel also solicited their expert opinions on how
things might have been done better, and what
things were done well that should be emulated.
Interviews were conducted to understand Chos
history, including his medical and mental health
treatment during his early school and university
years, and his interactions with the mental
health and legal systems. This included inter-
views with the Cho family, Chos high school
staff and faculty, staff and faculty at the univer-
sity, many of those involved with the mental
health treatment of Cho within and outside the
university (including the Cook Counseling Cen-
ter and his high school counseling), and members
of the legal community who had contact with
him. The assistance of attorney Wade Smith of
Raleigh, NC, was important in dealing with the
Cho family. He helped obtain signed releases
from the family and arranged an interview with
them. Various experts in mental health were
consulted on the problems with the mental
health and legal system within Virginia that
dealt with Cho. They also provided insight on
ways to identify and help such individuals in
other systems.
In evaluating the aftermaththe attempt to
mitigate the damage done to so many families,
members of the university community, and the
university itselfmany interviews were con-
ducted with family members of the victims, sur-
vivors and their families, people interacting with
the families and survivors, and others. The fam-
ily members were extended opportunities to
speak to the panel in public or private sessions,
as were the injured and some other survivors.
For these groups, everyone who requested an
interview was given one. Not all wanted inter-
views. Some wanted group interviews. Some
were ready to speak earlier or later than others.
To the best of the panels knowledge, and cer-
tainly its intent, all were accommodated. The
panel learned a great deal about the incident and
also confronted directly the indescribable grief
and loss experienced by so many. From families
and survivors, the panel learned about the posi-
tive aspects of the services provided after April
16 and also about the many perceived problems
with those services. The panel also considered
the many issues that the family members asked
to be included in the investigation. This input
CHAPTER I. BACKGROUND AND SCOPE
9
was invaluable and substantially improved this
report.
Most of the formal interviews were conducted by
one or two panel members, often with one or two
TriData staff present. Some were conducted
solely by staff. Generally, they were conducted in
private. No recordings or written transcripts
were made. All those interviewed were told that
the information they provided might be used in
the report but if they wished, they would not be
quoted or identified. These steps were taken to
encourage candor and to protect remarks that
were provided with the caveat that they not be
attributed to the speaker. The panel believes it
was able to obtain more candid and useful infor-
mation using this approach. Panel members and
staff had many informal conversations with col-
leagues in their fields to obtain additional
insights, generally not in formal settings.
Literature Research Especially toward the
beginning of the review but continuing through-
out, much research was undertaken on various
topics through the Internet and through infor-
mation sources suggested by panel members and
by individuals with whom the panel came into
contact. Many useful references were submitted
to the panel by the general public and experts.
Public Meetings A key part of the panels
review process was a series of four public meet-
ings held in different parts of the Commonwealth
to accommodate those who wished to contribute
information. The first meeting was held in Rich-
mond at the state capitol complex, followed by
meetings at Virginia Tech, George Mason
University, and the University of Virginia. This
facilitated input from the public and officials of
various universities on issues they all cared
deeply about. Several other universities offered
facilities besides those chosen, including some
out of state. Each university site was fully sup-
ported by their leadership, public relations
department, event planning staff, and campus
police. The Virginia State Police provided added
protection at the meetings. (The agendas of the
public meetings are given in Appendix C.)
In addition to the primary speakers, every public
meeting included time for public comment. In
some cases the people testifying were
representatives of lobbying groups,
organizations, and associations, but the panel
also heard from victims, family members of
victims, independent experts, and concerned
citizens. There was even one instance of a
cameraman who put his camera down and
testified. Generally, the public presenters were
expected to restrict themselves to a few minutes,
and most did not abuse the opportunity. At one
meeting, more people wanted to speak than time
available, even though the meeting was extended
an hour. Those not able to present information
still had the opportunity to submit it to the panel
through letters, e-mails, or phone calls, and
many did.
Web Site and Post Office Box Shortly
after the panel was formed, its staff created a
web site that was used both to inform the public
and to receive input from the public. It proved to
be very valuable. There was a minimum of spam
or inappropriate inputs. The web site was used
to post announcements of public meetings and to
post presentations made or visual aids used at
meetings. More than 400,000 hits were
recorded, with 26,000 unique visitors. The web
site also was advertised as a vehicle for anyone
to post information or opinions. As of August 9,
2007, more than 2,000 comments were posted
from experts in various fields as well as the gen-
eral public, victims, families of victims, and oth-
ers as follows:
Parents (self-identified) 251
General public 1,547
Educators 91
EMS 8
Students 48
Law enforcement officers 18
Family members of victims 12
Health professionals 102
Virginia Tech staff 2
Total 2,079
Most persons who submitted information to the
web site appeared sincere about making a
CHAPTER I. BACKGROUND AND SCOPE
10
contribution. Some lobbying groups on issues
such as gun control, carrying guns on campus,
and the influence of video games on young people
clearly urged their members to post comments.
A post office box also was opened for the public to
address comments directly to the panel. The
number of letters received was much smaller
than the number of e-mails but generally with a
high percentage of relevancy, especially from
experts, families, and victims.
Telephone Calls and E-Mails Some
information was received directly by panel mem-
bers or staff through phone calls or e-mails.
Much of this information was received by one
panel member or staff member and was shared
with others when thought important.
Panel Interactions The members of the
Virginia Tech Review Panel engaged on a per-
sonal level, participating in the majority of inter-
views conducted and exchanging many e-mails
and phone calls among themselves and with the
panel staff. The panel was impeded by the FOIA
rules that did not allow more than two members
to meet together or speak by phone without it
being considered a public meeting.
FINDINGS AND RECOMMENDATIONS
he panels findings and recommendations are
provided throughout the report. Recommen-
dations regarding the methodology used by the
panel are presented in Appendix D; they were
put in an appendix to avoid having the proce-
dural issues distract the reader from the heart of
the main issues.
The findings and related recommendations in
this report are of two kinds. The first comes from
reviewing actions taken in a time of crisis: what
was done very well, and what could have been
done better. Almost any crisis actions can be
improved, even if they were exemplary.
The second type of finding identifies major
administrative or procedural failings leading up
to the events, such as failing to connect the
dots of Chos highly bizarre behavior; the miss-
ing records at Cook Counseling Center; insensi-
tivity to survivors waiting to learn the fates of
their children, siblings, or spouses; and fund-
raising that appeared opportunistic.
To help in understanding the events, the report
begins in Chapter II with a description of the
setting of the Virginia Tech campus and its pre-
paredness for a disaster. In Chapter III, a
detailed timeline serves as a reference through-
out the reportthe succinct story of what hap-
pened, starting with Chos background, his
treatment, and then proceeding to the events of
April 16 and its aftermath. The events are elabo-
rated in subsequent chapters.
T
CHAPTER I. BACKGROUND AND SCOPE
10 - A
ADDITIONS AND CORRECTIONS
Time for Study: p. 5, Addition The Report noted that the Governor wanted the Report
completed by August 2007. A key motivation for this deadline was to get recommendations for
campus security improvements disseminated before the start of the school year in Virginia.
Also, the deadline was thought necessary to allow time for developing a legislative agenda
(suggested changes to laws and policies) needed to implement some of the Reports recommen-
dations in time for Virginias annual legislative session in January. Further, the Governor
wanted to get information out to the families of victims and to the general public as soon as
possible.
Access to Records: p. 7, Clarification The Report said thatultimately all records that
were requested [from Virginia Tech] and still existed were provided. At the time, Chos file at
the Cook Counseling Center was missing. An extensive search by Virginia Tech, including con-
tact with the previous CCC director, Dr. Miller, did not turn up the file, and no one knew if it
still existed. The file was found two years later by Dr. Miller in his home in response to a dis-
covery request by attorneys involved in a lawsuit.
Cooperativeness of University: pp. 7-8, Clarification Some victims families questioned
whether Virginia Tech should be characterized as extremely cooperative with the Review
Panel, and whether having a point of contact to obtain information and arrange interviews was
a barrier imposed by Virginia Tech. In fact, it was the Review Panel staff that requested a
point of contact to facilitate such things as finding and scheduling Virginia Tech faculty and
staff for interviews. Reporters, law enforcement officials, and others were pressing for inter-
views with many of the same Virginia Tech employees that the Review Panel wanted to inter-
view. Having a point of contact streamlined and prioritized the Review Panels access.
The person appointed by Virginia Tech to be the contact was highly cooperative and greatly fa-
cilitated obtaining information. Not surprisingly there were some Virginia Tech faculty and
staff who were guarded in discussions with the Review Panel possibly as a result of being in-
terviewed with other Virginia Tech officials present.

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11
Chapter II.
UNIVERSITY SETTING AND SECURITY
efore describing the details of the events, it
is necessary to understand the setting in
which they took place, including the security
situation at Virginia Tech at the time of the
shootings. This chapter focuses on the physical
security of the campus and its system for alert-
ing the university community in an emergency.
It also gives a brief background on the campus
police department and the universitys Emer-
gency Response Plan. The prevention aspect of
securityincluding the identification of people
who pose safety threatsis discussed in Chapter
IV.
UNIVERSITY SETTING
irginia Tech occupies a beautiful, sprawling
campus near the Blue Ridge Mountains in
southwest Virginia. It is a state school known for
its engineering and science programs but with a
wide range of other academic fields in the liberal
arts.
The main campus has 131 major buildings
spread over 2,600 acres. The campus is not
enclosed; anyone can walk or drive onto it. There
are no guarded roads or gateways. Cars can
enter on any of 16 road entrances, many of which
are not in line of sight of each other. Pedestrians
can use sidewalks or simply walk across grassy
areas to get onto the campus. Figure 1 shows
aerial views of the campus. There is a significant
amount of ongoing construction of new buildings
and renovation of existing buildings, with associ-
ated noise.
On April 16, the campus population was about
34,500, as follows:
26,370 students (9,000 live in dorms)
7,133 university employees (not
counting student employees)
1,000 visitors, contractors, transit
workers, etc.
34,503 Total
CAMPUS POLICE AND OTHER LOCAL
LAW ENFORCEMENT
key element in the security of Virginia Tech
is its police department. It is considered
among the leading campus police departments in
the state. While many campuses employ security
guards, the Virginia Tech Police Department
(VTPD) is an accredited police force. Its officers
are trained as a full-fledged police department
with an emergency response team (ERT), which
is like a SWAT team.
The police chief reports to a university vice
president.
On April 16, the VTPD strength was 35 officers.
It had 41 positions authorized but 6 were vacant.
The day shift, which comes on duty at 7 a.m., has
5 officers. Additionally, 9 officers work office
hours, 8 a.m. to 5 p.m., including the chief, for a
total of 14 on a typical weekday morning. On
April 16, approximately 34 of the officers came to
work at some point during the day.
The campus police could not handle a major
event by themselves with these numbers, and so
they have entered into a mutual aid agreement
with the Blacksburg Police Department (BPD)
for immediate response and assistance. They fre-
quently train together, and had trained for an
active shooter situation in a campus building
before the incident. As will be seen, this prepara-
tion was critical.
The VT campus police also have excellent work-
ing relationships with the regional offices of the
state police, FBI, and ATF. The high level of co-
operation was confirmed by each of the federal,
state, and local law enforcement agencies that
were involved in the events on April 16, and by
the rapidity of coordination of their response to
the incident and the investigation that followed.
Training together, working cases together, and
B
V
A
CHAPTER II. UNIVERSITY SETTING AND SECURITY
12

Figure 1. Aerial Views of Virginia Tech Campus

CHAPTER II. UNIVERSITY SETTING AND SECURITY
13
knowing each other on a first-name basis can be
critical when an emergency occurs and a highly
coordinated effort is needed.
The purpose of the Virginia Tech campus police
is stated in the universitys Emergency
Response Plan as follows: The primary purpose
of the VTPD is to support the academics
through maintenance of a peaceful and orderly
community and through provision of needed
general and emergency services. Although
some do not consider police department mission
statements of much importance versus how they
actually operate, the mission statement may
affect their role by indicating priorities. For
example, it may influence a decision as to
whether the university puts minimizing disrup-
tion to the educational process first and acting
on the side of precaution second. There are
many crimes and false alarms such as bomb
threats on campus, and it is often difficult to
make the decision on taking precautions that
are disruptive. The police mission statement
also may affect availability of student informa-
tion. Explicitly including the police under the
umbrella of university officials may allow them
to access student records under Family Educa-
tional Rights and Privacy Act (FERPA) regula-
tions.
Several leaders of the campus police chiefs of
Virginia commented that they do not always
have adequate input into security planning and
threat assessment or the authority to access
important information on students.
BUILDING SECURITY
he residence halls on campus require plac-
ing a student or staff keycard in an elec-
tronic card reader in order to enter between
10:00 p.m. and 10:00 a.m. A student access card
is valid only for his or her own dormitory and for
the mailbox area of another dormitory if ones
assigned mailbox is there.
Many other school buildings are considered pub-
lic spaces and are open 24 hours a day. The uni-
versity encourages students to use the facilities
for class work, informal meetings, and officially
sanctioned clubs and groups.
Most classrooms, such as those in Norris Hall,
have no locks. Staff offices generally do have
locks, including those in Norris Hall.
There are no guards at campus buildings or
cameras at the entrances or in hallways of any
buildings. Anyone can enter most buildings. It is
an open university.
Some buildings have loudspeaker systems
intended primarily for use of the fire depart-
ment in an emergency. They were not envi-
sioned for use by police. They can only be used
by someone standing at a panel in each building
and cannot be accessed for a campus-wide
broadcast from a central location.
This level of security is quite typical of many
campuses across the nation in rural areas with
low crime rates. Some universities are partially
or completely fenced, with guards at exterior
entrances; usually these are in urban areas.
Some universities have guards at the entrance
to each building and screen anyone coming in
without student or staff identification, again
usually on urban campuses. Some universities
have locks on classroom doors, but they typically
operate by key from the hallway. They are
intended to keep students and strangers out
when they are not in use and often cannot be
locked from the inside.
A few universities (e.g., Hofstra University in
Nassau County, NY) now have the ability to
lock the exterior doors of some or all buildings
at the push of a button in a central security
office. Most require manual operation of locks.
Virginia Tech would have to call people in scores
of buildings or send someone to the buildings to
lock their outside doors (except for dormitories
between 10 p.m. and 10 a.m. when they are
locked automatically).
T
CHAPTER II. UNIVERSITY SETTING AND SECURITY
14
Many levels of campus security existed at col-
leges and universities across Virginia and the
nation on April 16. A basic mission of institu-
tions of higher education is to provide a peace-
ful, open campus setting that encourages free-
dom of movement and expression. Different
institutions provide more or less security, often
based on their locations (urban, suburban, or
rural), size and complexity (from research uni-
versities to small private colleges), and
resources. April 16 has become the 9/11 for col-
leges and universities. Most have reviewed their
security plans since then. The installation of
security systems already planned or in progress
has accelerated, including those at Virginia
Tech.
Although the 2004 General Assembly directed
the Virginia State Crime Commission to study
campus safety at Virginias institutions of
higher education (HJR 122), the report issued
December 31, 2005, did not reflect the need for
urgent corrective actions. So far as the panel is
aware, there was no outcry from parents,
students, or faculty for improving VT campus
security prior to April 16. Most people liked the
relaxed and open atmosphere at Virginia Tech.
There had been concern the previous August
about an escaped convict and killer named
William Morva whose escape in the VT vicinity
unnerved many people. Also, some campus
assaults led some students to want to arm
themselves. However, if the April 16 incident
had not occurred, it is doubtful that security
issues would be on the minds of parents and
students more than at other universities, where
the most serious crimes tend to be rapes,
assaults, and dangerous activity related to
alcohol or drug abuse by students. These issues
were addressed by the State Crime Commission
Report and were given an average level of
attention at Virginia Tech.
CAMPUS ALERTING SYSTEMS
irginia Tech was in the process of upgrading
its campus-wide alerting system in spring
2007.
Existing System Virginia Tech had the ca-
pability on April 16 to send messages to the stu-
dent body, faculty, and other staff via a broad-
cast e-mail system. The associate vice president
for University Relations had the authority and
capability to send a message from anywhere
that was connected to the web. Almost every
student and faculty member on campus has a
computer and e-mail address (estimated at 96
percent by the university). Most but not all stu-
dent computers are portable. Many are carried
to classes. However, an e-mail message sent by
the university may not get read by every user
within minutes or even hours. The e-mail sys-
tem had 36,000 registered e-mail addresses.
Distribution of an emergency message occurred
at a rate of about 10,000 per minute.
The university also has a web site that it uses to
post emergency warnings, mostly for weather
events. The system has high-volume capacity.
(As events unfolded on April 16, the VT web site
was receiving 148,000 visits per hour.) An
emergency message can be put in a box on the
web site that anyone reaching the site would see
no matter what they were looking for.
The university also has contacts with every local
radio and TV station. The Virginia Tech associ-
ate vice president for University Relations has a
code by which he can send emergency messages
to the stations that could be played immedi-
ately. This process could take 20 minutes or so
because each station has its own code to vali-
date the sender. The validation codes are neces-
sary because students or members of the public
could send spoof messages to the media as a
prank. The public media are used for the occa-
sional weather emergencies, and the campus
community is trained to tune in to get further
information.
An estimated 96 percent of students at Virginia
Tech carry cell phones according to the univer-
sity. Most bring them to classes or wherever else
they go. A text message to cell phones probably
will reach more students faster than an e-mail
message because the devices are more portable
and can be rung. But some are forgotten, turned
V
CHAPTER II. UNIVERSITY SETTING AND SECURITY
15
off, or intentionally not carried. The university
was still in the process of installing a text mes-
saging system on April 16 and had no way to
send a message to all cell phones.
Personal digital assistants (or PDAs) such as
Blackberries are used by fewer students and
faculty than cell phones because they are more
expensive and are not as capable as computers.
They have the capacity to receive e-mails and
would be treated either as a computer or as a
phone or both, depending on how it is regis-
tered.
The university also has a broadcast phone-mail
system that allows it to send a phone message
to all phone numbers registered with its mes-
saging system. VT used this system to send
messages to all faculty offices and some stu-
dents on April 16. Students and faculty must
voluntarily register their phones with this sys-
tem if they want to be notified. It takes time to
reach all the phones; 11 separate actions are
required to send a broadcast message to all reg-
istered numbers, said the associate vice presi-
dent for University Relations. It is not a useful
approach when time is critical.
A university switchboard with up to four opera-
tors is working during normal business hours. It
can handle hundreds of calls per hour.
To augment the range of messaging systems it
had available, the university was in the process
of installing six outdoor loudspeakers to make
emergency announcements. Some are mounted
on buildings and others on poles, as shown in
Figure 2. They can be used for either a voice
message or an audible alarm (such as a siren).
Four had been installed and were used on April
16, but they did not play a significant role in
this incident. (The announcement was made
after the 9:05 a.m. class period in which the
mass shooting had already started.)
As part of its emergency planning, the univer-
sity has another system in place as a last-ditch
resortusing resident advisors in dorms and
floor wardens in some older classroom and office
Figure 2. One of the Six Sirens Being
Installed on Virginia Tech Campus
buildings to personally spread a warning. In
Norris Hall, for example, the chairman of the
Engineering Mechanics Department, whose
office was on the second floor, said he had been
issued a bullhorn to make announcements and
was instructed to rap on classroom and office
doors to alert people if there was an emergency
and other notification systems failed, if a per-
sonal approach was needed to convey safety
information, or if an evacuation or sheltering in
place was required.
New Unified Campus Alerting System
In spring 2007, Virginia Tech was in the process
of installing a unified, multimedia messaging
system to be completed before the next semes-
ter. It would allow university officials to send an
emergency message that would flow in parallel
to computers, cell phones, PDAs, and tele-
phones. The message could be sent by anyone
who is registered in the system as having
authority to send one, using a code word for
validation. The president of the university or
associate vice president of University Relations
CHAPTER II. UNIVERSITY SETTING AND SECURITY
16
can be anywhere and send a message to every-
oneall that is needed is an Internet connec-
tion.
Students must be registered with the new sys-
tem to receive messages. A student can provide
a mobile phone number, e-mail address(es), or
instant messaging system to be contacted in an
emergency. Parents numbers can be included.
All students and staff are encouraged but not
required to register with the new system. Each
user can set the priority order in which their
devices are to be called. The message will cas-
cade through the hierarchy set by each user
until it gets answered.
1
This system has the
enormous advantage of transmitting a message
to the entire university community in less than
a minute.
For the Virginia Tech community of about
35,000 users, the system will cost $33,000 a
year to operate and no out-of-pocket expense to
start. However, it takes considerable staff time
to select a system and then oversee its startup.
The operating cost is a function of the band-
width used and the frequency of messages. The
more people and devices on the system and the
more messages sent per year, the higher the
cost. Initially, Virginia Tech is planning to use
the system only for emergency messages. Other
schools have started using such systems for
more routine purposes such as sending informa-
tion about special events on campus and admin-
istrative information, at an extra charge.
Virginia Tech was willing to share the criteria it
used in its selection of a messaging system
(Appendix E). Several competing commercial
options have excellent capabilities. Some are
only suitable for small schools. Universities and
colleges need to balance their needs and the sys-
tem capability versus costs.
Message Content and Authorization A
critical part of security is not only having the

1
A system being developed sends a message to anyone
within range of a tower or set of towers. It does not matter
who you are or whether you have registered; if you have a
cell phone and are in range, you get the message.
technical communication capability of reaching
students and staff quickly, but also planning
what to say and how quickly to say it. Pursuant
to its Emergency Response Plan in effect on
April 16, the Virginia Tech Policy Group and the
police chief could authorize sending an emer-
gency message to all students and staff. Typi-
cally, the police chief would make a decision
about the timing and content of a message after
consultation with the Policy Group, which is
comprised of the president and several other
vice presidents and senior officials. This process
of having the Policy Group decide on the mes-
sage was used during the April 16 incidents.
However, while the Virginia Tech campus police
had the authority to send a message, they did
not have the technical means to do so. Only two
people, the associate vice president for Univer-
sity Relations and the director of News and
Information, had the codes to send a message.
The police could not access the alerting system
to send a message. . The police had to contact
the university leadership on the need and pro-
posed content of a message. As a matter of
course, the police would usually be consulted if
not directly involved in the decision regarding
the sending of an alert for an emergency.
There are no preset messages for different types
of emergencies, as some public agencies have in
order to speed crafting of an emergency mes-
sage. All VT messages are developed for the par-
ticular incident.
The timing and content of the messages sent by
the university are one of the major controversies
concerning the events of April 16. (Chapter VIII
addresses the double homicide at West Ambler
Johnston residence hall and the messaging deci-
sions that followed).
EMERGENCY RESPONSE PLAN
he universitys Emergency Response Plan
deals with preparedness and response to a
variety of emergencies, but nothing specific to
shootings. The version in effect on April 16 was
about 2 years old. Emergencies such as weather
T
CHAPTER II. UNIVERSITY SETTING AND SECURITY
17
problems, fires, and terrorism were in the fore of
VT emergency planning pre-April 16.
2

The plan addresses different levels of emergen-
cies, designated as levels 0, I, II, and III. The
Norris Hall event was level III, the highest,
based on the number of lives lost, the physical
and psychological damage suffered by the
injured, and the psychological impact on a very
large number of people.
The plan calls for an official to be designated as
an emergency response coordinator (ERC) to
direct a response. It also calls for the establish-
ment of an emergency operations center (EOC).
Satellite operations centers may be established
to assist the ERC. As will be discussed in
describing the response to the events, there
were multiple coordinators and multiple opera-
tions centers but not a central EOC on April 16.
Two key decision groups are identified in the
Emergency Response Plan: the Policy Group
and the Emergency Response Resources Group.
The Policy Group is comprised of nine vice
presidents and support staff, chaired by the
university president. The Policy Group deals
with procedures to support emergency opera-
tions and to determine recovery priorities. In
the events of April 16, it also decided on the
messages sent and the immediate actions taken
by the university after the first incident as well
as the second mass shooting. The Policy Group
sits above the emergency coordinator for an in-
cident. It does not include a member of the cam-
pus police, but the campus police are usually
asked to have a representative at its meetings.
The second key group, the Emergency Response
Resources Group (ERRG), includes a vice presi-
dent designated to be in charge of an incident,
police officials, and others depending on the
nature of the event. It is to ensure that the
resources needed to support the Policy Group
and needs of the emergency are available. The
ERRG is organized and directed by the emer-

2
Appendix F has an example of the active shooter part of
the University of Virginias plan, and something similar
should be included in the Virginia Tech plan.
gency response coordinator. The ERRG is sup-
posed to meet at the EOC. Decisions made by
these groups and their members on April 16 are
addressed in the remainder of the report, as the
event is described.
The VT Emergency Response Plan does not deal
with prevention of events, such as establishing a
threat assessment team to identify classes of
threats and to assess the risk of specific prob-
lems and specific individuals. There are threat
assessment models used elsewhere that have
proven successful. For example, at two college
campuses in Virginia, the chief operating officer
receives daily reports of all incidents to which
law enforcement responded the previous day,
including violation of the student conduct code
up to criminal activity. This information is then
routinely shared with appropriate offices which
are responsible for safety and health on campus.
KEY FINDINGS
he Emergency Response Plan of Virginia
Tech was deficient in several respects. It did
not include provisions for a shooting scenario
and did not place police high enough in the
emergency decision-making hierarchy. It also
did not include a threat assessment team. And
the plan was out of date on April 16; for exam-
ple, it had the wrong name for the police chief
and some other officials.
The protocol for sending an emergency message
in use on April 16 was cumbersome, untimely,
and problematic when a decision was needed as
soon as possible. The police did not have the
capability to send an emergency alert message
on their own. The police had to await the delib-
erations of the Policy Group, of which they are
not a member, even when minutes count. The
Policy Group had to be convened to decide
whether to send a message to the university
community and to structure its content.
The training of staff and students for emergen-
cies situations at Virginia Tech did not include
shooting incidents. A messaging system works
more effectively if resident advisors in dormito-
ries, all faculty, and all other staff from janitors
T
CHAPTER II. UNIVERSITY SETTING AND SECURITY
18
to the president have instruction and training
for coping with emergencies of all types.
It would have been extremely difficult to lock
down Virginia Tech. The size of the police force
and absence of a guard force, the lack of elec-
tronic controls on doors of most buildings other
than residence halls, and the many unguarded
roadways pose special problems for a large rural
or suburban university. The police and security
officials consulted in this review did not think
the concept of a lockdown, as envisioned for
elementary or high schools, was feasible for an
institution such as Virginia Tech.
It is critical to alert the entire campus popula-
tion when there is an imminent danger. There
are information technologies available to rapidly
send messages to a variety of personal commu-
nication devices. Many colleges and universities,
including Virginia Tech, are installing such
campus-wide alerting systems. Any purchased
system must be thoroughly tested to ensure it
operates as specified in the purchase contract.
Some universities already have had problems
with systems purchased since April 16.
An adjunct to a sophisticated communications
alert system is a siren or other audible warning
device. It can give a quick warning that some-
thing is afoot. One can hear such alarms regard-
less of whether electronics are carried, whether
the electronics are turned off, or whether elec-
tric power (other than for the siren, which can
be self-powered) is available. Upon sounding,
every individual is to immediately turn on some
communication device or call to receive further
instructions. Virginia Tech has installed a sys-
tem of six audible alerting devices of which four
were in place on April 16. Many other colleges
and universities have done something similar.
No security cameras were in the dorms or any-
where else on campus on April 16. The outcome
might have been different had the perpetrator of
the initial homicides been rapidly identified.
Cameras may be placed just at entrances to
buildings or also in hallways. However, the
more cameras, the more intrusion on university
life.
Virginia Tech did not have classroom door locks
operable from the inside of the room. Whether to
add such locks is controversial. They can block
entry of an intruder and compartmentalize an
attack. Locks can be simple manually operated
devices or part of more sophisticated systems
that use electromechanical locks operated from
a central security point in a building or even
university-wide. The locks must be easily
opened from the inside to allow escape from a
fire or other emergency when that is the safer
course of action. While adding locks to class-
rooms may seem an obvious safety feature, some
voiced concern that locks could facilitate rapes
or assaults in classrooms and increase univer-
sity liability. (An attacker could drag someone
inside a room at night and lock the door, block-
ing assistance.) On the other hand, a locked
room can be a place of refuge when one is pur-
sued. On balance, the panel generally thought
having locks on classroom doors was a good
idea.
Shootings at universities are rare events, an
average of about 16 a year across 4,000 institu-
tions. Bombings are rarer but still possible.
Arson is more common and drunk driving inci-
dents more frequent yet. There are both simple
and sophisticated improvements to consider for
improving security (besides upgrading the alert-
ing system). A risk analysis needs to be per-
formed and decisions made as to what risks to
protect against.
There have been several excellent reviews of
campus security by states and individual cam-
puses (for example, the states of Florida and
Louisiana, the University of California, and the
University of Maryland). The Commonwealth of
Virginia held a conference on campus security
on August 13, 2007.
The VTPD and BPD were well-trained and had
conducted practical exercises together. They had
undergone active shooter training to prepare for
the possibility of a multiple victim shooter.
The entire police patrol force must be trained in
the active shooter protocol, because any officer
may be called upon to respond.
CHAPTER II. UNIVERSITY SETTING AND SECURITY
19
It was the strong opinion of groups of Virginia
college and university presidents with whom the
panel met that the state should not impose
required levels of security on all institutions,
but rather let the institutions choose what they
think is appropriate. Parents and students can
and do consider security a factor in making a
choice of where to go to school.
Finally, the panel found that the VTPD state-
ment of purpose in the Emergency Response
Plan does not reflect that law enforcement is the
primary purpose of the police department.
RECOMMENDATIONS
EMERGENCY PLANNING
II-1 Universities should do a risk analysis
(threat assessment) and then choose a level
of security appropriate for their campus.
How far to go in safeguarding campuses, and
from which threats, need to be considered by
each institution. Security requirements vary
across universities, and each must do its own
threat assessment to determine what security
measures are appropriate.
II-2 Virginia Tech should update and
enhance its Emergency Response Plan and
bring it into compliance with federal and
state guidelines.
II-3 Virginia Tech and other institutions of
higher learning should have a threat
assessment team that includes representa-
tives from law enforcement, human
resources, student and academic affairs,
legal counsel, and mental health functions.
The team should be empowered to take actions
such as additional investigation, gathering
background information, identification of addi-
tional dangerous warning signs, establishing a
threat potential risk level (1 to 10) for a case,
preparing a case for hearings (for instance,
commitment hearings), and disseminating
warning information.
II-4 Students, faculty, and staff should be
trained annually about responding to vari-
ous emergencies and about the notification
systems that will be used. An annual
reminder provided as part of registration should
be considered.
II-5 Universities and colleges must comply
with the Clery Act, which requires timely
public warnings of imminent danger.
Timely should be defined clearly in the federal
law.
CAMPUS ALERTING
II-6 Campus emergency communications
systems must have multiple means of shar-
ing information.
II-7 In an emergency, immediate messages
must be sent to the campus community that
provide clear information on the nature of
the emergency and actions to be taken The
initial messages should be followed by update
messages as more information becomes known.
II-8 Campus police as well as administra-
tion officials should have the authority and
capability to send an emergency message.
Schools without a police department or senior
security official must designate someone able to
make a quick decision without convening a
committee.
POLICE ROLE AND TRAINING
II-9 The head of campus police should be a
member of a threat assessment team as well
as the emergency response team for the
university. In some cases where there is a
security department but not a police depart-
ment, the security head may be appropriate.
II-10 Campus police must report directly to
the senior operations officer responsible for
emergency decision making. They should be
part of the policy team deciding on emergency
planning.
II-11 Campus police must train for active
shooters (as did the Virginia Tech Police
Department). Experience has shown that wait-
ing for a SWAT team often takes too long. The
CHAPTER II. UNIVERSITY SETTING AND SECURITY
20
best chance to save lives is often an immediate
assault by first responders.
II-12 The mission statement of campus
police should give primacy to their law
enforcement and crime prevention role.
They also must to be designated as having a
function in education so as to be able to review
records of students brought to the attention of
the university as potential threats. The lack of
emphasis on safety as the first responsibility of
the police department may create the wrong
mindset, with the police yielding to academic
considerations when it comes time to make deci-
sions on, say, whether to send out an alert to the
students that may disrupt classes. On the other
hand, it is useful to identify the police as being
involved in the education role in order for them
to gain access to records under educational pri-
vacy act provisions.
Specific findings and recommendations on police
actions taken on April 16 are addressed in the
later chapters.


CHAPTER II. UNIVERSITY SETTING AND SECURITY
20 - A
ADDITIONS AND CORRECTIONS
Multijurisdictional Police Training: p. 8, Correction Campus and Blacksburg police
had trained together for an active shooter incident as was noted in the Report, but the training
was conducted in an empty school building off campus, not on campus.
Mailbox Access and Targeting of Initial Victim: p. 11, Clarification Some students
were assigned mailboxes located in a different dorm from their own. They could access their
mailbox after 7:30 a.m. Cho was one of these students. He lived in Harper Hall but his mailbox
was in West Ambler Johnston where he committed the first two murders. He had access and
reason to be in the mailbox area of WAJ, which may help explain why he chose it. It also was a
short walk from his dorm. His motivation for the initial killings still has not been determined.
He had no known relationship with Emily Hilscher, nor with her roommate. It is not known
and may never be known whether he had targeted Ms. Hilscher beforehand or just happened
upon her that fateful morning.
Reason for Closely Held Alert Code: p. 14, Addition Access codes were required in order
to send messages on the campus alerting system and to distribute information to the local me-
dia stations at least in part because students had previously sent prank messages about non-
existent emergencies. Virginia Tech wanted the alerting system to prevent unauthorized alerts
and to validate the emergency messages they broadcast.
Joint Homicide Investigation: p. 18, Addition While the Virginia Tech and Blacksburg
Police Departments had trained and worked well together, neither had ever investigated a
homicide before April 16, 2007. The State Police did have extensive homicide investigation ex-
perience, and VTPD requested immediate State Police assistance in the investigation of the
shooting.
OTHER COMMENTS
1. Frequency of Campus Shootings: Commenter wanted text on page 18 to read that
shootings are becoming more frequent, rather than rare, events.
Response: There was no data provided which showed an increasing trend in frequency over
recent years compared to earlier years. The data provided did not focus on universities.
2. On-Duty Psychiatrist at CCC: Commenter claimed that there was no psychiatrist on
duty at the CCC after Dr. Millers departure until the arrival of Dr. Flynn.
Response: There were several psychiatrists on duty during this time period. Dr. Miller was
reassigned in January/February 2006. From January through April 2006, Dr. Gary Rooker,
a Virginia Tech employee, was the psychiatrist available to assist students. Dr. Brian
Bladykus was hired in June of 2006 and worked through February of 2007. Dr. Joseph
Frieben was hired half-time August 10, 2006 and full-time on July 1, 2007. Thus, there was
a psychiatrist available except for a one-month period in May 2006. When Dr. Flynn started
in September 2006, both Dr. Bladykus and Dr. Frieben were at the CCC. Also, throughout
this period, Vicki Arbuckle, a psychiatric nurse practitioner, was on staff.
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21
Chapter III.
REVISED TIMELINE OF EVENTS
he modifications to this chapter resulted primarily from additional information identified
and made available since the original Report was published.
In constructing both the original and the revised timelines, care was taken to confirm the dates
and times through multiple sources where possible.. However, even with the newly available
information, some of the times provided are approximate, because not every message, phone
call and event was time-stamped. In a few cases where no documentation existed it was neces-
sary to rely on individuals best recollections of times. Many of the interviews for the original
timeline were conducted in the weeks immediately after the shootings. Some individuals re-
ported dates and times as they knew them to be true at that time; however, in a few cases they
were misinformed. The revised timeline corrects those errors and adds more details.
The original wording of the timeline generally was preserved except where new information
required a change or addition.
he following timeline provides highlights of
the events leading up to the tragedy on April
16,2007 the actions taken on April 16, and some
subsequent actions. The time scale switches from
years to months to days and even to minutes as
appropriate. The timeline is an overview and
composite of major events, with additional facts
and details discussed in the respective chapters.
Therefore, the timeline does not include all the
details covered later in the chapters, but, rather,
is intended to serve as a framework for the
reader. The timeline and the Report begin with
Seung Hui Chos childhood and end with Gover-
nor Kaines declaration of a day of mourning,
April 20, 2007.
The information here was drawn from numerous
interviews, written sources, and briefings. The
Cho family and Seung Hui Chos school adminis-
trators, counselors, teachers, and medical and
school records are the prime sources for his his-
tory prior to attending Virginia Tech.
Information obtained about his Virginia Tech
years before the shootings came from interviews
with faculty, counselors, administrators, police,
courts, psychological evaluators, suitemates, and
others. The panel also had access to many Vir-
ginia Tech, medical, and court records and to e-
mails and other written materials involving Cho.
The timeline for the events of April 16 relied
primarily on Virginia Tech Police Department
(VTPD) and Virginia State Police (VSP) reports
and interviews, supplemented by interviews with
survivors, Virginia Tech officials, emergency
medical responders, hospitals, state officials and
others.
The information on the aftermath drew on medi-
cal examiner records, interviews with families
and other sources.
Each aspect of the timeline is discussed further
in the following chapters, with an evaluation as
well as narration of events.
PRE-INCIDENTS: CHOS HISTORY
19862000
1984 Seung Hui Cho is born to a fam-
ily living in a small two-room apartment in
Seoul, South Korea. He is an inordinately
shy, quiet child, but no problem to his fam-
ily. He has serious health problems from 9
months to 3 years old, is frail, and after
unpleasant medical procedures does not
want to be touched.
1992 Chos family emigrates to Mary-
land when he is 8 years old.
T
T
CHAPTER III. REVISED TIMELINE OF EVENTS
22
1993 The Cho family moves to Fairfax
County, Virginia, when he is 9 years old.
They work long hours in a dry-cleaning
business.
1997 Seung Hui in the 6th grade con-
tinues to be very withdrawn. Teachers meet
with his parents about this behavior. In the
summer before he enters 7th grade, he
begins receiving counseling at the Center for
Multicultural Human Services to address
his shy, introverted nature, which is diag-
nosed as selective mutism. Parents try to
socialize him more by encouraging extracur-
ricular activities and friends, but he re-
mains withdrawn.
1999 During the 8th grade, one of
Chos writings for a teacher depicts suicidal
and homicidal ideations. The paper refer-
ences and celebrates the Columbine shoot-
ings in April of this year. The school re-
quests that his parents ask a counselor to
intervene, which leads to a psychiatric
evaluation at the Multicultural Center for
Human Services. He is prescribed antide-
pressant medication. He responds well and
is taken off the medication approximately
one year later.
20002003 (High School)
Fall 2000 Cho starts Westfield High School
in Fairfax County as a sophomore, after at-
tending another high school in Centreville
for a year. After review by the local screen-
ing committee, he is diagnosed as having
an emotional disability and is enrolled in an
Individual Educational Program (IEP) to
deal with his shyness and lack of respon-
siveness in a classroom setting. Art therapy
(his selective mutism rules out talk therapy
as an effective treatment mode) continues
with the Multicultural Center for Human
Services through his junior year. He has no
behavior problems, keeps his appointments,
and makes no threats. He gets good grades
and adjusts reasonably to the school envi-
ronment. The guidance office in the school
believes he has been academically successful
and the therapist notes he has made limited
progress in communicating.
June 2003 Cho graduates from Westfield
High School with a 3.5 GPA in the Honors
Program. He decides to attend Virginia Tech
against the advice of his parents and coun-
selors, who think that it is too large a school
for him and that he will not receive ade-
quate individual attention. He is given the
name of a contact at the high school if he
needs help in college, but never avails him-
self of it.
20032004 (Virginia Tech)
August 2003 Cho enters Virginia Tech as a
business information systems major. Little
attention is drawn to him during his fresh-
man year. He has a difficult time with his
roommate over neatness issues and changes
rooms. His parents make weekly trips to
visit him. His grades are good. He does not
see a counselor at school or home. He is
excited about college.
Fall 2004 Cho begins his sophomore year.
Cho moves off campus to room with a senior
who is rarely at home. Cho complains of
mites in the apartment, but doctors tell him
it is acne and prescribe minocycline. He be-
comes interested in writing. His grades be-
gin to slip so he decides he will switch his
major to English beginning his junior year.
His sister notes a growing passion for writ-
ing over the winter break, though he is se-
cretive about its content. Cho submits a
book idea to a publishing house.
2005 (Virginia Tech)
Spring 2005 Cho requests a change of major to
English. The idea for a book sent to a New
York publishing house is rejected. This
seems to depress him, according to his fam-
ily. He still sees no counselor at school or
CHAPTER III. REVISED TIMELINE OF EVENTS
23
home, and exhibits no behavioral problems
other than his quietness.
Fall 2005 Cho starts his junior year and
moves back into the dorms. Serious prob-
lems begin to surface. His sister notes that
he is writing less at home, is less enthusias-
tic, and wonders if the publishers rejection
letter curbed his enthusiasm for writing. At
school, Cho is taken to some parties by his
suitemates at the start of the semester. On
one such occasion he stabs at the carpet in
student Margaret Bowmans room with a
knife, in the presence of his suitemates.
October 15 English Professor Nikki Giovanni
writes a letter to Cho expressing her con-
cern about his behavior in her class and
about violence in his writing. She offers to
help get him into another class.
Professor Giovanni asks department chair
Dr. Lucinda Roy to remove Cho from her
class.
October 18 Dr. Roy informs Mary Ann Lewis,
Associate Dean of Liberal Arts and Human
Sciences, and others that Cho read a violent
and upsetting poem in Professor Gio-
vannis class that day, and that her students
said Cho had been surreptitiously taking
photos of them. Dr. Roy also says she has
contacted Tom Brown (Dean of Student Af-
fairs), Zenobia Hikes (Vice President of Stu-
dent Affairs), Detective George Jackson at
Virginia Tech Police Department (VTPD),
and Dr. Robert Miller at the Cook Counsel-
ing Center (CCC), to report the incident and
seek advice. Tom Brown advises Dr. Roy she
can remove Cho from Professor Giovannis
class as long as a viable alternative is of-
fered.
CCC advises that though the poem is dis-
turbing, there is no specific threat. They
suggest that Cho be referred to the CCC.
Frances Keene (Director of Judicial Affairs)
and Tom Brown both write to Dr. Roy indi-
cating their concurrence with this plan.
Brown tells Dr. Roy to advise Cho that any
future similar behavior will be referred [to
Judicial Affairs].
October 19 Dr. Roy and Cheryl Ruggiero
meet with Cho regarding his situation in
Professor Giovannis class, discuss the im-
pact of his writing on the class, and warn
that unauthorized picture-taking is inap-
propriate, and is taken seriously by Virginia
Tech. Cho says his writing was intended as
satire and agrees not to take any more pho-
tos of classmates or professors. Cho is ad-
vised of the study alternative available. He
is advised to seek counseling. This is reiter-
ated in an e-mail to Cho following the meet-
ing.
Following the above, Dr. Roy removes Cho
from Professor Giovannis class and tutors
him one-on-one with assistance from Profes-
sor Frederick DAguiar. Cho refuses to go to
counseling, and Dr. Roy tells this to the Di-
vision of Student Affairs, the CCC, the
Schiffert Health Center, the Virginia Tech
police, and the College of Liberal Arts and
Human Sciences. Chos problems are dis-
cussed at a meeting of Virginia Techs Care
Team that reviews students with problems.
Care Team members discuss the arrange-
ment worked out to remove Cho from Pro-
fessor Giovannis class and tutor him and
that Dr. Roy had met with Cho and docu-
mented the results. The Care Team consid-
ers the problem solved.
November 2 Chos roommates and dorm resi-
dents think Cho set fires in a dorm lounge
and say in emails that they reported it to po-
lice. However, no written police report ex-
ists.
November 27 Jennifer Nelson, a resident of
West Ambler Johnston (WAJ) resident hall
in room 4021, files a report with VTPD indi-
cating that Cho has made annoying con-
tact with her on the Internet, by phone, and
in person. VTPD interviews Cho, but Nelson
declines to press charges, though she says
she would testify at a disciplinary hearing.
The investigating officer refers the incident
CHAPTER III. REVISED TIMELINE OF EVENTS
24
to the schools disciplinary system, the Of-
fice of Judicial Affairs. The Office of Judici-
ary Affairs later contacts Nelson, telling her
they can only proceed if she files a written
complaint. She declines and no hearing is
held.
November 30 Cho calls CCC and is triaged (i.e.,
given a preliminary screening) by phone fol-
lowing his interaction with VTPD.
December 6 E-mails among resident advisors
(RAs) reflect complaints by another female
student, Christina Lillizu, who lives on the
3
rd
floor of Cochrane resident hall, regarding
derogatory instant messages (IMs) with foul
language sent from Cho under various
strange aliases. The RAs also report the in-
cidents of IMs Cho to Jennifer Nelson, and
his visit in disguise to her dorm room.
Lisa Virga, a resident advisor, sends an e-
mail to Rohsaan Settle, a member of the
Residence Life staff, detailing a list of com-
plaints about Cho, including a report that he
has knives in his room. Virga is concerned
that no one in the dorms has confronted Cho
directly and she thinks someone should talk
to him. Settle responds with an e-mail to
Virga saying they should chat about the
knives.
December 9 Cho sends unwanted IM to a
third female student, Margaret Bowman
(306 Campbell Hall). Later, he leaves mes-
sages on her marker board outside her
room.
December 11 Cho leaves a new message, a
quote from Shakespeare, on Bowmans
marker board.
December 12 Bowman returns from an exam
and finds more text added to the message
from 12/11. She then files a report with the
VTPD complaining of the multiple disturb-
ing contacts from Cho. She requests that
Cho have no further contact with her. When
questioned by students about the notes to
Bowman, Cho tells them Shakespeare did
it.
VTPD goes to Chos room, but he is not
there. They leave a message for him with
his roommates.
Cho calls and cancels a 2:00 p.m. appoint-
ment at CCC but then calls back in the af-
ternoon and is triaged for the second time by
phone.
December 13 VTPD notifies Cho that he is to
have no further contact with Margaret
Bowman. After campus police leave, Chos
suitemate receives an IM from Cho stating,
I might as well kill myself now. The
suitemate alerts VTPD. The police take Cho
to the VTPD where a prescreener from the
New River Valley Community Services
Board (CSB) evaluates him as an imminent
danger to self or others. A magistrate is-
sues a temporary detaining order, and Cho
is transported to Carilion St. Albans Psychi-
atric Hospital for an overnight stay and
mental evaluation. No one contacts Chos
parents.
December 14
7 a.m. The person assigned as an inde-
pendent evaluator, psychologist Roy Crouse,
evaluates Cho and concludes that he does
not present an imminent danger to himself.
Before 11 a.m. A staff psychiatrist at St. Albans
evaluates Cho, concludes he is not a danger
to himself or others, and recommends outpa-
tient counseling. He gathers no collateral in-
formation.
1111:30 a.m. Special Justice Paul M. Barnett
conducts Chos commitment hearing and
rules in accordance with the independent
evaluator, but orders follow-up treatment as
an outpatient. Cho then makes an appoint-
ment with the CCC and is released.
Noon The St. Albans staff psychiatrist
dictates in his evaluation summary that
there is no indication of psychosis, delu-
CHAPTER III. REVISED TIMELINE OF EVENTS
25
sions, suicidal or homicidal ideation. The
psychiatrist finds that his insight and
judgment are normalFollow-up and after-
care to be arranged with the counseling cen-
ter at Virginia Tech; medications, none.
2:25 p.m. CCC receives a fax from Carilion
Health System with copies of the St. Albans
discharge summary and the Pre-admission
Screening Form completed by the CSB
evaluator the previous day at police head-
quarters.
3:00 p.m. Cho appears for his appointment
and is triaged at the CCC for the third time
in 15 days.
Dr. Miller, the CCC director, receives an
email notifying him that Cho had been
taken to St. Albans the previous night. Dr.
Miller e-mails CCC staff to alert them in
case this student is seen at the CCC. A
CCC staff member e-mails back that Cho al-
ready has been seen that afternoon.
2006
January The CCC receives a psychiatric
summary from St. Albans. No action is
taken by CCC or the Care Team to follow up
on Cho.
February Dr. Miller is removed from his
position following a management study of
the CCC. In his hurry to vacate the office, he
packs Chos file and files of several other
students in a box and takes them home.
(This is only discovered in July, 2009.)
April 17 Chos technical writing professor,
Carl Bean, suggests that Cho drop his class
after repeated efforts to address shortcom-
ings in class and inappropriate choice of
writing assignments. Cho follows the profes-
sor to his office, raises his voice angrily, and
is asked to leave. Professor Bean does not
report this incident to Virginia Tech offi-
cials.
Spring Cho takes Professor Bob Hicoks
creative writing class. Professor Hicok later
characterizes Chos writing as not particu-
larly unique as far as subject matter is con-
cerned, but remarkable for violence.
Fall Cho enrolls in a playwriting
workshop taught by Professor Ed Falco. Cho
writes a play concerning a young man who
hates the students at his school and plans to
kill them and himself. The writing contains
parallels to the subsequent events of April
16, 2007, as well as the recorded messages
sent to NBC that same day.
Professor Falco confers with Professors Roy
and Norris, who tell him that in Fall 2005
and in 2006, Dr. Roy and Dr. Norris, respec-
tively, had alerted Associate Dean Mary
Ann Lewis about Cho.
September 612 Professor Lisa Norris, another of
Chos writing professors, alerts Associate
Dean Mary Ann Lewis about him, but the
dean finds no mention of mental health is-
sues or police reports on Cho. Professor
Norris encourages Cho to go to counseling
with her, but he declines.
September 26November 4 Cho writes three more
violent stories for an English class.
2007
February 2 Cho orders a .22 caliber Walther
P22 handgun online from TGSCOM, Inc.
February 9 Cho picks up the handgun from
J-N-D Pawnbrokers in Blacksburg, across
the street from Virginia Tech.
March 12 Cho rents a van from Enterprise
Rent-A-Car at the Roanoke Regional Air-
port, which he keeps for almost a month.
(Cho videotapes some of his subsequently
released diatribe in the van.)
March 13 Cho purchases a 9mm Glock 19
handgun and a box of 50 9mm full metal
jacket practice rounds at Roanoke Firearms.
CHAPTER III. REVISED TIMELINE OF EVENTS
26
Cho waited the 30 days between gun pur-
chases as required by Virginia law. The
store initiates the required background
check by police, who find no record of mental
health issues.
March 22 Cho goes to PSS Range and
Training, an indoor pistol range, and spends
an hour practicing.
March 22 Cho purchases two 10-round
magazines for the Walther P22 on eBay.
March 23 Cho purchases three additional
10-round magazines from another eBay
seller.
March 31 Cho purchases additional ammu-
nition magazines, ammunition, and a hunt-
ing knife from Wal-Mart and Dicks Sport-
ing Goods. He buys chains from Home
Depot.
Cho gets a speeding ticket, his first police
contact since December 2005.
April 7 Cho purchases more ammunition.
April 8 Cho spends the night at the
Hampton Inn in Christiansburg, Virginia,
videotaping segments for his manifesto-like
diatribe. He also buys more ammunition.
April 13 Bomb threats are made to
Torgersen, Durham, and Whittemore halls
in the form of an anonymous note. The
threats are assessed by the VTPD, and the
buildings evacuated. There is no lockdown
or cancellation of classes elsewhere on cam-
pus. Later, during the investigation of the
April 16 murders, no evidence is found link-
ing these threats to Chos bomb threat note
in Norris Hall, based in part on handwriting
analysis.
April 14 An Asian male wearing a hooded
garment is seen by a faculty member in
Norris Hall. The faculty member later (after
April 16) tells police that one of her students
had told her the doors were chained. This
may have been Cho practicing. Cho buys yet
more ammunition.
April 15 Cho places his weekly Sunday
night call to his family in Fairfax County.
They report the conversation as normal and
that Cho said nothing that caused them con-
cern.
THE INCIDENTS
April 16, 2007
5:00 a.m. In Chos suite in Harper Hall
(2121), one of Chos suitemates notices Cho
is awake and at his computer.
About 5:30 a.m. One of Chos other suitemates
notices Cho clad in boxer shorts and a shirt
brushing his teeth and applying acne cream.
Cho returns from the bathroom, gets
dressed, and leaves.
About 6:45 a.m. Cho is spotted by a student loiter-
ing in the foyer area of WAJ resident hall,
between the exterior door and the locked in-
terior door. He has access to the mailbox
foyer, but not to the interior of the building.
7:02 a.m. Emily Hilscher enters WAJ, her
dorm, after being dropped off by her boy-
friend, Karl Thornhill. (The time is based on
her swipe card record.)
About 7:15 a.m. Cho shoots Hilscher in her room
(4040) where he also shoots Ryan Christo-
pher Clark, an RA. Clark, it is thought,
most likely came to investigate noises in
Hilschers room, which is next door to his.
Both of the victims wounds ultimately prove
to be fatal. Cho exits the scene, leaving be-
hind bloody footprints and shell casings.
7:17 a.m. Chos access card is swiped at
Harper Hall (his nearby residence hall). He
goes to his room to change out of his bloody
clothes, cancel his computer account, and
make other preparations for what is to
come.
CHAPTER III. REVISED TIMELINE OF EVENTS
27
7:20 a.m. The VTPD receives a call on their
administrative telephone line advising that
a female student in room 4040 of WAJ had
possibly fallen from her loft bed. The caller
was given this information by another WAJ
resident near room 4040 who heard the
noise.
7:21 a.m. The VTPD dispatcher notifies the
Virginia Tech Rescue Squad that a female
student had possibly fallen from her loft bed
in WAJ.
7:22 a.m. A VTPD officer is dispatched to
room 4040 at WAJ to accompany the Vir-
ginia Tech Rescue Squad, which is also dis-
patched per standard protocol.
7:24 a.m. The VTPD officer arrives at WAJ
room 4040, finds two people shot inside the
room, and immediately requests additional
VTPD resources.
7:25 a.m. Cho accesses his university
e-mail account (based on computer records).
He erases his files and the account.
7:26 a.m. Virginia Tech Rescue Squad 3
arrives on-scene outside WAJ.
7:27 a.m. Police dispatcher is advised of
two victims. Officer on scene requests su-
pervisor.
7:29 a.m. Virginia Tech Rescue Squad 3
arrives at room 4040.
7:30 a.m. Additional VTPD officers begin
arriving at room 4040. They secure the
crime scene and in effect lock down the
dormitory, with police inside and outside.
Police start preliminary investigation. In-
terviews with residents fail to produce a
suspect description. No one on Hilschers
floor in WAJ saw anyone leave room 4040
after the initial noise was heard.
A housekeeper in Burruss Hall tells Dr. Ed
Spencer, Associate Vice President for Stu-
dent Affairs and member of the Policy
Group, that an RA in WAJ was murdered.
(The housekeeper had received a phone call
from another housekeeper in WAJ.)
7:35a .m. Police on the scene at WAJ say
they need a detective.
7:40 a.m. VTPD Chief Flinchum is notified
by phone of the WAJ shootings. Chief
Flinchum tries repeatedly to reach the Of-
fice of the Executive Vice President.
7:51 a.m. Chief Flinchum contacts the
Blacksburg Police Department (BPD) and
requests a BPD evidence technician and
BPD detective to assist with the investiga-
tion.
7:55 a.m. Dr. Spencer arrives at WAJ after
walking from Burruss Hall. He calls Dr. Ze-
nobia Hikes.
7:57 a.m. Chief Flinchum finally gets
through to the Virginia Tech Office of the
Executive Vice President and notifies them
of the shootings.
8:00 a.m. Classes begin. Chief Flinchum
arrives at WAJ and finds VTPD and BPD
detectives on the scene. A local special agent
of the Virginia State Police (VSP) has been
contacted and is responding to the scene.
The VTPD, BPD, and soon the VSP start to
process the crime scene in Hilschers room
(4040) and gather evidence. They then can-
vass the dorm for possible witnesses, search
interior and exterior waste containers and
surrounding areas near WAJ for evidence,
and canvass rescue squad personnel for ad-
ditional evidence or information.
About 8:00 a.m. The Virginia Tech Center for
Professional and Continuing Education
locks down on its own.
8:05 a.m. At least two Policy Group
members notify their families of the
shootings.
8:10 a.m. President Steger is notified by a
secretary that there has been a shooting. He
CHAPTER III. REVISED TIMELINE OF EVENTS
28
tells her to get Chief Flinchum on the
phone.
8:11 a.m. Chief Flinchum talks to Presi-
dent Steger via phone and reports one stu-
dent is critical, one is fatally wounded, and
the incident seems to be domestic in nature.
He reports no weapon found and there are
bloody footprints. President Steger tells
Chief Flinchum to keep him informed. A
staff member of the Policy Group and Presi-
dent Steger discuss the event, and Steger
decides to convene the Policy Group no later
than 8:30 a.m.
8:11 a.m. BPD Chief Kim Crannis arrives
on scene.
8:13 a.m. Chief Flinchum requests addi-
tional VTPD and BPD officers to assist with
securing WAJ entrances and with the inves-
tigation. He also orders recall of all off-shift
personnel.
8:14 a.m. Hilschers roommate, Heather
Hough, arrives at WAJ to go with Hilscher
to chemistry class. (Time recorded from
swipe card.)
8:15 a.m. Chief Flinchum requests the
VTPD Emergency Response Team (ERT) to
respond to the scene and then to stage in
Blacksburg in the event an arrest is needed
or a search warrant is to be executed.
8:168:40 a.m. Hilschers roommate, Heather
Haugh, is interviewed inside WAJ by detec-
tives. She explains that on Monday morn-
ings Hilschers boyfriend, Karl Thornhill,
usually drops her off at WAJ and returns to
Radford University where he is a student.
She says he owns guns and practices shoot-
ing. Police then seek Thornhill as a person
of interest. His vehicle is not found in cam-
pus parking lots and officers believe he has
left campus. VTPD and BPD officers are
sent to his home, but he is not there. The
Thornhill home is then put under surveil-
lance until Thornhill is found.
Shortl y after 8:16 a.m. Chief Flinchum informs the
Policy Group that there is a person of
interest who is probably now off campus.
8:169:24 a.m. Police continue canvassing WAJ
for possible witnesses. VTPD, BPD, and the
VSP continue processing Hilschers room
(4040) crime scene and gathering evidence.
Investigators secure identification of the vic-
tims. Police allow students in WAJ to leave;
Some go to 9:00 a.m. classes in Norris Hall.
8:19 a.m. Chief Crannis requests BPD ERT
to respond for the same reason as the VTPD
ERT.
8:20 a.m. A person fitting Chos description
is seen near the Duck Pond on campus.
8:25 a.m. The Policy Group convenes to
plan how to notify students of the double
shooting.
Police cancel bank deposit pickups.
8:40 a.m. Chief Flinchum tells President
Steger in a phone update that Hilschers
boyfriend is a person of interest and proba-
bly off campus. A Policy Group member noti-
fies the Governors office of the double shoot-
ing.
8:408:45 a.m. Phone calls are made from BPD
to its units and to Montgomery County
Sheriffs Office and Radford University po-
lice to be on the lookout for Thornhills vehi-
cle.
8:45 a.m. A Policy Group member e-mails a
Richmond colleague saying one student is
dead and another critically wounded.
Gunman on the loose, he says, adding
This is not releasable yet.
8:49 a.m. The same Policy Group member
reminds his Richmond colleague, just try to
make sure it doesnt get out.
8:50 a.m. First period classes end. The Pol-
icy Group begins composing a notice to the
university about the shootings in WAJ. The
Associate Vice President for University Re-
CHAPTER III. REVISED TIMELINE OF EVENTS
29
lations, Larry Hinkler, is unable to send the
message at first due to technical difficulties
with the alert system.
8:52 a.m. Blacksburg public schools lock
down until more information is available
about the incident at Virginia Tech. School
superintendent notifies school board of this
by e-mail.
The Virginia Tech Government Affairs Di-
rector orders the university presidents of-
fice to be locked.
9:00-9:15 a.m. Virginia Tech veterinary college
locks down.
9:01 a.m. Cho mails a package from the
Blacksburg post office to NBC News in New
York that contains pictures of himself hold-
ing weapons, an 1,800-word rambling dia-
tribe, and video clips in which he expresses
rage, resentment, and a desire to get even
with oppressors. He alludes to a coming
massacre. Cho prepared this material in the
previous weeks. The videos are a perform-
ance of the enclosed writings. Cho also mails
a letter to the English Department attack-
ing Professor Carl Bean, with whom he pre-
viously argued.
9:05 a.m. Classes begin for the second
period in Norris Hall.
Virginia Tech trash pickup is cancelled.
9:15 a.m. Both police ERTs are staged at
the BPD in anticipation of executing search
warrants or making an arrest.
9:159:30 a.m. Cho is seen outside and then
inside Norris Hall, an engineering building,
by several students. He is familiar with the
building because one of his classes meets
there. He chains the doors shut on the three
public entrances, from the inside. No one
reports seeing him do this. A faculty mem-
ber finds a bomb threat note attached to an
inner door near one of the chained exterior
doors. She gives it to a janitor to carry to the
Engineering School deans office on the third
floor.
9:24 a.m. A Montgomery County deputy
sheriff initiates a traffic stop of
Hilschers boyfriend in his pickup truck off
campus. He had heard there had been a
shooting and was driving back to the cam-
pus to search for Hilscher after she did not
answer his calls. Detectives are sent to as-
sist with the questioning.
A VTPD police captain joins the Policy
Group as police liaison and provides updates
as information becomes available. He re-
ports one gunman at large, possibly on foot.
9:26 a.m. Virginia Tech administration
sends e-mail to campus staff, faculty, and
students informing them of the dormitory
shooting.
About 9:30a.m. Radford University Police had
received a request from BPD to look up
Thornhills class schedule and find him in
class. Before they can do this they get a sec-
ond call that he has been found and stopped
on the road.
9:30 a.m. Police pass information to the
Policy Group that it is unlikely that Hil-
schers boyfriend, Thornhill, is the shooter
(though he remains a person of interest).
9:319:48 a.m. A VSP trooper arrives at the traf-
fic stop of Thornhill and helps question him.
A gunpowder residue test is performed and
packaged for lab analysis. (There is no im-
mediate result from this type of test in the
field.)
About 9:40 a.m.39:51 a.m.Cho begins shooting in
room 206 in Norris Hall, where a graduate
engineering class in Advanced Hydrology is
underway. Cho kills Professor G. V. Logana-

3
The Review Panel estimates that the shooting began at
about this time, allowing for about a minute for the students
and faculty in the room next door to recognize that the
sounds being heard were gunshots, and then make the first
call to 9-1-1.
CHAPTER III. REVISED TIMELINE OF EVENTS
30
than and other students in the class, killing
9 and wounding 3 of the 13 students.
Cho goes across the hall from room 206 and
enters room 207, an Elementary German
class. He shoots teacher Christopher James
Bishop, then students near the front of the
classroom and starts down the aisle shoot-
ing others. Cho leaves the classroom to go
back into the hall.
Students in room 205, attending Haiyan
Chengs class on Issues in Scientific Com-
puting, hear Chos gunshots. (Cheng was a
graduate assistant substituting for the pro-
fessor that day.) The students barricade the
door and prevent Chos entry despite his fir-
ing at them through the door.
Meanwhile, in room 211 Madame Jocelyne
Couture-Nowak is teaching French. She and
her class hear the shots, and she asks stu-
dent Colin Goddard to call 9-1-1. A student
tells the teacher to put the desk in front of
the door, which is done, but it is nudged
open by Cho. Cho walks down the rows of
desks shooting people. Goddard is shot in
the leg. Student Emily Haas picks up the
cell phone Goddard dropped. She begs the
police to hurry. Cho hears Haas and shoots
her, grazing her twice in the head. She falls
and plays dead, though keeping the phone
cradled under her head and the line open.
Cho says nothing on entering the room or
during the shooting. (Three students who
pretend to be dead survive.)
9:41 a.m. A BPD dispatcher receives a call
regarding the shooting in Norris Hall. The
dispatcher initially has difficulty under-
standing the location of the shooting. Once
identified as being on campus, the call is
transferred to VTPD.
9:42 a.m. The first 9-1-1 call reporting
shots fired reaches the VTPD. A message is
sent to all county EMS units to staff and
respond.
9:45 a.m. The first police officers arrive at
Norris Hall, a three-minute response time
from their receipt of the call. Hearing shots,
they pause briefly to check whether they are
being fired upon, then rush to one entrance,
and then another but find the doors chained
shut. An attempt to shoot open the chain or
lock on one door fails.
About 9:45 a.m. The police inform the admini-
stration that there has been another shoot-
ing. Virginia Tech President Steger hears
sounds like gunshots, and sees police run-
ning toward Norris Hall.
Back in room 207, the German class, two
uninjured students and two injured stu-
dents go to the door and hold it shut with
their feet and hands, keeping their bodies
away. Within 2 minutes, Cho returns. He
beats on the door and opens it an inch and
fires shots around the door handle, then
gives up trying to get in.
Cho returns to room 211, the French class,
and goes up one aisle and down another,
shooting people again. Cho shoots Goddard
two more times.
A janitor sees Cho in the hall on the second
floor loading his gun; the janitor flees down-
stairs.
Cho tries to enter room 204 where engineer-
ing professor Liviu Librescu is teaching
Mechanics. Professor Librescu braces his
body against the door yelling for students to
head for the window. He is shot through the
door. Students push out screens and jump or
drop to grass or bushes below the window.
Ten students escape this way. The next two
students trying to escape are shot. Cho
returns again to room 206 and shoots more
students.
9:50 a.m. Using a shotgun, police shoot
open the ordinary key lock of a Norris Hall
entrance that goes to a machine shop and
that could not be chained. These officers
hear gunshots as they enter the building.
CHAPTER III. REVISED TIMELINE OF EVENTS
30 - A
They immediately follow the sounds to the
second floor.
Triage and rescue of victims begin.
A second e-mail is sent by the administra-
tion to all Virginia Tech e-mail addresses
announcing that A gunman is loose on
campus. Stay in buildings until further
notice. Stay away from all windows. Four
outside loudspeakers on poles broadcast a
similar message.
Virginia Tech and Blacksburg police ERTs
arrive at Norris Hall, including one para-
medic with each team.
9:51 a.m. Cho shoots himself in the head
just as police reach the second floor. Investi-
gators believe that the police shotgun blast
alerted Cho to police (starting entry into the
building). Chos shooting spree in Norris
Hall lasted about 11 minutes. He fired 174
rounds, and killed 30 people in Norris Hall
plus himself, and wounded 17.
The first team of officers begins securing the
second floor and aiding survivors from mul-
tiple classrooms. They also get a prelimi-
nary description of the suspected gunman,
and try to determine if there are additional
gunmen.
9:52 a.m. The police clear the second floor
of Norris Hall. Two tactical medics attached
to the ERTs, one medic from Virginia Tech
Rescue and one from Blacksburg Rescue, are
allowed to enter to start their initial triage.
9:53 a.m. The 9:42 a.m. request for all EMS
units is repeated.
10:08 a.m. A deceased male student is dis-
covered by police team and suspected to be
the gunman:
No identification is found on the body.
He appears to have a self-inflicted gun-
shot wound to the head.
He is found among his victims in class-
room 211, the French class.
Two weapons are found near the body.
10:17 a.m. A third e-mail from Virginia Tech
administration cancels classes and advises
people to stay where they are.
10:51 a.m. All patients from Norris Hall
have been transported to a hospital or
moved to a minor treatment unit.
10:52 a.m. A fourth e-mail from Virginia
Tech administration warns of a multiple
shooting with multiple victims in Norris
Hall, saying the shooter is in custody and
that as routine procedure police are search-
ing for a second shooter.
10:57 a.m. A report of shots fired at the ten-
nis courts near Cassell Coliseum proves
false.
12:42 p.m. Virginia Tech President Charles
Steger announces that police are releasing
people from buildings and that counseling
centers are being established.
1:35 p.m. A report of a possible gunshot
near Duck Pond proves to be another false
alarm.
4:01 p.m. President George W. Bush speaks
to the Nation from the White House regard-
ing the shooting.
5:00 p.m. The first deceased victim is
transported to the medical examiners office.
8:45 p.m. The last deceased victim is
transported to the medical examiners office.
Evening Police continue investigating
whether Karl Thornhill, Emily Hilschers
boyfriend, is linked to her murder and that
of Ryan Clark because the ballistics analysis
that later ties together the WAJ and the
Norris Hall murders (confirming that Chos
guns were used at both incidents) is not yet
completed. The Blacksburg ERT, including
Virginia Tech and Montgomery County Po-
CHAPTER III. REVISED TIMELINE OF EVENTS
30 - B
lice, enters Thornhills home and searches it.
The ERT searches his residence. Using
standard procedures, ERT members hand-
cuff Thornhill and his family who have come
to console him. They are put on the floor
while the search is made, because Thornhill
is known to own firearms. The search is
highly upsetting to Thornhill and his family.
POST-INCIDENT
April 17, 2007
9:15 a.m. VTPD releases the name of the
shooter as Seung Hui Cho and confirms 33
fatalities between the two incidents.
9:30 a.m. Virginia Tech announces classes
will be cancelled for the remainder of the
week to allow students the time they need to
grieve and seek assistance as needed.
11:00 a.m. A family assistance center is
established at The Inn at Virginia Tech.
2:00 p.m. A convocation ceremony is held
for the university community at the Cassell
Coliseum. Speakers include President
George W. Bush, Virginia Governor Tim
Kaine (who had returned from Japan),
Virginia Tech President Charles Steger,
Virginia Tech Vice President for Student
Affairs Zenobia L. Hikes, local religious
leaders (representing the Muslim, Buddhist,
Jewish, and Christian communities), Pro-
vost Dr. Mark G. McNamee, Dean of Stu-
dents Tom Brown, Counselor Dr. Christo-
pher Flynn, and poet Professor Nikki Gio-
vanni.
8:00 p.m. A candlelight vigil is held on the
Virginia Tech drill field.
11:30 p.m. The first autopsy is completed.
April 18, 2007
8:25 a.m. A SWAT team enters Burruss
Hall, a campus building next to Norris Hall,
responding to a suspicious event; this
proves to be a false alarm.
4:37 p.m. Local police announce that NBC
News in New York just received by mail a
package containing images of Cho holding
weapons, his writings, and his video
recordings. NBC immediately submitted
this information to the FBI. A fragment of
the video and pictures are widely broadcast.
April 19, 2007
Virginia Tech announces that all students
who were killed will be granted posthumous
degrees in the fields in which they were
studying. The degrees are subsequently
awarded to the families at the regular com-
mencement exercises, or privately, or in one
case, at a Corps of Cadets event in Fall
2007.
Governor Kaine appoints an independent
Virginia Tech Review Panel to review the
shootings.
Autopsies on all victims are completed by
the medical examiner. The autopsy of Cho
found no gross brain function abnormalities
and no toxic substances, drugs, or alcohol
that could explain the rampage.
April 20, 2007
Governor Kaine declares a statewide day of
mourning.

31
Chapter IV.
MENTAL HEALTH HISTORY OF SEUNG HUI CHO
This chapter is divided into two parts: Part A, the mental health history of Cho, and Part B, a
discussion of Virginias mental health laws.


ne of the major charges Governor Kaine
gave to the panel was to develop a profile
of Cho and his mental health history. In this
chapter, developmental periods of Chos life
are discussed, followed by an assessment and
recommendations to address policy gaps or
system flaws. The chapter details his involun-
tary commitment for mental health treatment
while at Virginia Tech. It also examines the
particular warning signs during Chos junior
year at Virginia Tech and the universitys
ability to identify and respond appropriately
to students who may present a danger to
themselves and others.
Information was gleaned from many sources.
One of the most significant was a 3-hour
interview with Chos parents and sister. The
family stated that they were willing to help in
any way with the panels work, and felt inca-
pable of redressing the loss for other families.
They expressed heartfelt remorse, and they
apologized to the families whose spouse, son,
or daughter was murdered or injured. The
Chos have said that they will mourn, until
the day they die, the deaths and injuries of
those who suffered at the hands of their son.
Chos sister, Sun, interpreted the answers to
every question posed to Mr. and Mrs. Cho. At
the end of the interview, they had portrayed
the person they knew as a son and brother,
someone who was startlingly different from
the one who carried out premeditated murder.
Other sources of information included:
Hundreds of pages of transcripts and
records from Westfield High School,
Virginia Tech, and various medical offices and
mental health treatment centers.
Interviews with high school staff and adminis-
trators where Cho attended school, faculty
and staff at Virginia Tech, and several of
Chos suitemates, roommates, and resident
advisors in the dormitories.
Interviews with staff at the Center for Multi-
cultural Human Services, the Cook Counsel-
ing Center, the Carilion Health System, spe-
cial justices, and Virginia Tech police.
The tape and written records of Chos hearing
before special justice Barnett.
The report of the Inspector General for Mental
Health, Mental Retardation and Substance
Abuse Services, Investigation of April 16, 2007
Critical Incident at Virginia Tech.
EARLY YEARS
ho was born in Korea on January 18, 1984,
the second child of Sung-Tae Cho and Hyang
Im Cho. Both parents were raised in two-parent
families that included the paternal grandmother;
there was extended family support. The families
did not encounter the level of deprivation that
many did in post-war Korea. The Chos recall that
a paternal uncle in Korea committed suicide.
Their first child, daughter Sun Kyung, was born 3
years before Seung Hui.
When he was 9 months old, Cho developed
whooping cough, then pneumonia, and was
hospitalized. Doctors told the Chos that their son
had a hole in his heart (some records say heart
murmur). Two years later, doctors conducted
cardiac tests to better examine the inside of his
heart that included a procedure (probably an
O
C
Part A Mental Health History of Seung Hui Cho
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
32
echocardiograph or a cardiac catherization).
This caused the 3-year-old emotional trauma.
From that point on, Cho did not like to be
touched. He generally was perceived as
medically frail. According to his mother, he
cried a lot and was constantly sick.
In Korea, Cho had a few friends that he would
play with and who would come over to the
house. He was extremely quiet but had a
sweet nature. In Korea, quietness and calm-
ness are desired attributescharacteristics
equated with scholarliness; even so, his intro-
verted personality was so extreme that his
family was very concerned.
In 1992, the family moved to the United
States to pursue educational opportunities for
their children. They were encouraged by Mr.
Chos sister who had immigrated before them.
Mrs. Cho began working outside the home for
the first time in order to make ends meet. The
transition was difficult: none of the family
spoke English. Both children felt isolated. The
parents began a long period of hard labor and
extended work hours at dry cleaning busi-
nesses. English was not required to do their
work, so both there and at home they spoke
Korean.
Sun stated that her brother seemed more
withdrawn and isolated in the United States
than he had been in Korea. She recalled that
at times they were made fun of, but she took
it in stride because she thought this was just
a given. In about 2 years, the children began
to understand, read, and write English at
school. Korean was spoken at home, but Cho
did not write or read Korean.
For the first 6 months in the United States,
the Chos lived with family members in Mary-
land. They moved to a townhouse for 1 year,
after which they relocated to Virginia, living
in an apartment for 3 years. The move to Vir-
ginia occurred in the middle of third grade for
Cho. He was 9 years old. Chos only known
friendship was with a boy next door with
whom he went swimming.
Sun and her parents recall that Cho seemed to be
doing better. He was enrolled in a Tae Kwon Do
program for awhile, watched TV, and played video
games like Sonic the Hedgehog. None of the video
games were war games or had violent themes. He
liked basketball and had a collection of figurines
and remote controlled cars. Years later when he
was in high school, Cho was asked to write about
his hobbies and interests. He wrote:
I like to listen to talk shows and alternative
stations, and I like action moviesMy favor-
ite movie is X-Men, favorite actor is Nicolas
Cage, favorite book is Night Over Water, fa-
vorite band is U2, favorite sport is basketball,
favorite team is Portland Trailblazers, favor-
ite food is pizza, and favorite color is green.
Transportation to and from extracurricular activi-
ties was a problem because both parents worked
long hours trying to save money to buy a town-
house, which they accomplished a few years later.
The parents recalled that Cho had to wait for
transport back and forth all the time.
The parents reported no disciplinary problems
with their son. He was quiet and gentle and did
not exhibit tantrums or angry outbursts. The fam-
ily never owned weapons or had any in the house.
At one point after Cho was in college, his mother
found a pocket knife in one of his drawers, and
she expressed her disapproval. He had few duties
or responsibilities at home, except to clean his
room. He never had a job during summers or over
school breaks, either in high school or in college.
The biggest issue between Cho and his family was
his poor communication, which was frustrating
and worrisome to them. Over the years, Cho spoke
very little to his parents and avoided eye contact.
According to one record the panel reviewed, Mrs.
Cho would get so frustrated she would shake him
sometimes. He would talk to his sister a little, but
avoided discussing his feelings and reactions to
things or sharing everyday thoughts on life,
school, and events. If called upon to speak when a
visitor came to the home, he would develop sweaty
palms, become pale, freeze, and sometimes cry.
Frequently, he would only nod yes or no.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
33
Mrs. Cho made a big effort to help Cho become
better adjusted, and she would talk to him,
urging him to open up, to have more cour-
age. The parents urged him to get involved in
activities and sports. They worried that he
was isolating himself and was lonely. Other
family members asked why he would not talk.
He reportedly resented this pressure. Mr. Cho,
having a quiet nature himself, was slightly
more accepting of his sons introspective and
withdrawn personality, but he was stern on
matters of respect. Cho and his father would
argue about this. According to one of the re-
cords reviewed, Chos father would not praise
his son. Where Chos later writings included a
father-son relationship, the character of the
father was always negative. Cho never talked
about school and never shared much. His
mother and sister would ask how he was doing
in school, trying to explore the possibility of
bullying. His sister knew that when he
walked down school hallways a few students
sometimes would yell taunts at him. He did
not talk about feelings or school at all. He
would respond okay to all questions about
his well being.
Cho, as a special needs child, generated a high
level of stress within the family. Adaptation to
cope with this stress can produce both positive
and negative results. The family dynamic
which evolved in the Chos to cope with this
stress was that of rescue behavior and more
coddling of Cho who seemed unreachable emo-
tionally. There was some friction between Cho
and his sister, however, nothing that appeared
as other than normal sibling rivalry. In fact,
Sun was the one to whom Cho spoke the most.
Key Findings of Early Years
Chos early development was character-
ized by physical illness and inordinate
shyness.
Even as a young boy, Cho preferred not to
speak, a situation that worried and frus-
trated his parents.
He was ostracized by some peers, though
he did not discuss this with his family.
His parents worked very long hours and had
financial difficulties. They worried about the
effect of this on their children because they
had less than optimum time to devote to par-
enting.
Medical records did not indicate a diagnosis of
mental illness prior to coming to the United
States.
ELEMENTARY SCHOOL IN VIRGINIA
ho was enrolled in the English as a Second
Language (ESL) program in Virginia as soon
as he arrived in the middle of third grade. The
family at this time was living in a small apart-
ment. School teachers indicated that Cho would
not interact socially, communicate verbally, or
participate in group activities. One teacher
reported that he did play with one student during
recess.
Cho was referred to the schools educational
screening committee because teachers believed his
communication problems stemmed more from
emotional issues than from language barriers.
When Cho was in sixth grade, his parents bought
a townhouse next to the school so he could easily
commute to his classes. The school requested a
parentteacher conference because Cho was not
answering any questions in class. Mrs. Cho took
an interpreter with her to the parent-teacher con-
ference. She resolved to find friends for him and
encouraged both their children to go to the church
she attended. Because the congregation was
small, however, there were few children, so both
Cho and his sister lost interest and stopped going
to church.
One of Mrs. Chos friends urged her to look into
another church that reportedly had a minister
who could help people with problems like Chos.
She occasionally attended that church over a 6-
month period, but decided against reaching out to
that pastor to work with her son. Several news-
paper articles that appeared after the shooting
reported that the pastor from that church had
worked directly with Cho. According to Mrs. Cho,
those reports are untrue. Mrs. Cho did register
her son for a 1-week summer basketball camp
C
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
34
sponsored by that church, but she never
sought its help on personal matters.
Mrs. Cho tried to be extra nurturing to Cho.
He did not reject her attempts at socialization
per se, but he disliked talking. Finally, Chos
parents decided to let him be the way he is
and not force him to interact and talk with
others. He never spoke of imaginary friends.
He did not seem to be involved in a fantasy
world or to be preoccupied by themes in his
play or work that caused concern. He never
talked of a twin brother. The parents char-
acterization of him was a very gentle, very
tender, and good person.
MIDDLE SCHOOL YEARS
he summer before Cho started seventh
grade, his parents followed up on a rec-
ommendation from the elementary school that
they seek therapy for Cho. In July 1997, the
Chos took their son to the Center for Multi-
cultural Human Services (CMHS), a mental
health services facility that offers mental
health treatment and psychological evalua-
tions and testing to low-income, English-
limited immigrant and refugee individuals.
They told the specialists of their concern about
Chos social isolation and unwillingness to dis-
cuss his thoughts or feelings.
Mr. and Mrs. Cho overcame several obstacles
to get their son the help he needed. In order
for Cho to make his weekly appointments at
the center, they had to take turns leaving
work early to drive him there. There were cul-
tural barriers as well. In the familys native
country, mental or emotional problems were
signs of shame and guilt. The stigmatization
of mental health problems remains a serious
roadblock in seeking treatment in the United
States too, but in Korea the issue is even more
relevant. Getting help for such concerns is
only reluctantly acknowledged as necessary.
After starting with a Korean counselor with
whom there was a poor fit, Cho began working
with another specialist who had special train-
ing in art therapy as a way of diagnosing and
addressing the emotional pain and psychological
problems of clients. Typically, this form of therapy
is used with younger children who do not have
sufficient language or cognitive skills to utilize
traditional talk therapy. Because Cho would not
converse and uttered only a couple words in
response to questions, art therapy was one way to
reach him. The specialist offered clay modeling,
painting, drawing, and a sand table at each ses-
sion. Cho would choose one of the options. As he
worked, the therapist could ascertain how he was
feeling and what his creations might represent
about his inner world. Then she talked to him
about what his work indicated and hoped to help
him progress in being more socially functional. He
modeled houses out of clay, houses that had no
windows or doors.
Chos therapist noted that while explaining the
meaning of Chos artwork to him, his eyes some-
times filled with tears. She never saw anything
that he wrote. Eventually, Cho began to make eye
contact. She saw this as a start toward becoming
healthier.
Cho also had a psychiatrist who participated in
the first meeting with Cho and his family and
periodically over the next few years. He was diag-
nosed as having [severe] social anxiety disorder.
It was painful to see, recalled one of the psychia-
trists involved with Chos case. The parents were
told that many of Chos problems were rooted in
acculturation challengesnot fitting in and diffi-
culty with friends. Personnel at the center also
noted in his chart that he had experienced medi-
cal problems and that medical tests as an infant
and as a preschooler had caused emotional
trauma. Records sent to Chos school at the time
(following a release signed by his parents) and the
tests administered by mental health professionals
evaluated Cho to be a much younger person than
his actual age, which indicated social immaturity,
lack of verbal skills, but not retardation. His
tested IQ was above average.
Cho continued to isolate himself in middle school.
He had no reported behavioral problems and did
not get into any fights. Then, in March 1999,
when Cho was in the spring semester of eighth
T
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
35
grade, his art therapist observed a change in
his behavior. He began depicting tunnels and
caves in his art. In and of themselves, those
symbols were not cause for alarm, but Cho
also suddenly became more withdrawn and
showed symptoms of depression. In that con-
text, the therapist felt that the tunnels and
caves were red flags. She was concerned and
asked him whether he had any suicidal or
homicidal thoughts. He denied having them,
but she drew up a contract with him anyway,
spelling out that he would do no harm to him-
self or to others, and she told him to commu-
nicate with his parents or someone at school if
he did experience any ideas about violence.
That is just what he did, in the form of a pa-
per he wrote in class.
The following month, April 1999, the murders
at Columbine High School occurred. Shortly
thereafter, Cho wrote a disturbing paper in
English class that drew quick reaction from
his teacher. Chos written words expressed
generalized thoughts of suicide and homicide,
indicating that he wanted to repeat Colum-
bine, according to someone familiar with the
situation. No one in particular was named or
targeted in the words he wrote. The school
contacted Chos sister since she spoke English
and explained what had happened. The family
was urged to have Cho evaluated by a psy-
chiatrist. The sister relayed this information
to her parents who asked her to accompany
Cho to his next therapy appointment and
report the incident, which she did. The thera-
pist then contacted the psychiatrist for an
evaluation.
Cho was evaluated in June 1999 by a psychia-
trist at the Center for Multicultural Human
Services. There, psychiatric interns from The
George Washington University Hospital pro-
vide treatment one day a week supervised by
other doctors at GWU. Cho was fortunate
because the intern who was his psychiatrist
was actually an experienced child psychiatrist
and family counselor who had practiced in
South America prior to coming to the United
States. He had to recertify in this country and
was in the process of doing that at GWU Hospital
when he first met Cho.
Mr. and Mrs. Cho explained to the psychiatrist
that they were facing a family crisis since their
daughter would be leaving home in the fall to
attend college and she was the family member
with whom Cho communicated, as limited as that
communication was. They feared that once their
daughter was no longer home, he would not com-
municate at all. The psychiatrist also was
informed of the disturbing paper Cho had written.
The doctor diagnosed Cho with selective mutism
and major depression: single episode. He pre-
scribed the antidepressant Paroxetine 20 mg,
which Cho took from June 1999 to July 2000. Cho
did quite well on this regimen; he seemed to be in
a good mood, looked brighter, and smiled more.
The doctor stopped the medication because Cho
improved and no longer needed the antidepres-
sant.
Selective mutism is a type of an anxiety disorder
that is characterized by a consistent failure to
speak in specific social situations where there is
an expectation of speaking. The unwillingness to
speak is not secondary to speech/communication
problems, but, rather, is based on painful shyness.
Children with selective mutism are usually inhib-
ited, withdrawn, and anxious with an obsessive
fear of hearing their own voice. Sometimes they
show passive-aggressive, stubborn and controlling
traits. The association between this disorder and
autism is unclear.
Major depression refers to a predominant mood of
sadness or irritability that lasts for a significant
period of time accompanied by sleep and appetite
disturbances, concentration problems, suicidal
ideations and pervasive lack of pleasure and
energy. Major depression typically interferes with
social, occupational and educational functioning.
Effective treatments for depression and selective
mutism include psychotherapy and anti depres-
sants/anti-anxiety agents such as Selective Sero-
tonin Reuptake Inhibitors (SSRIs).
It should be noted that when the subject of Chos
eighth grade paper and subsequent evaluation
was discussed with Mr. and Mrs. Cho and Chos
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
36
sister during the interview, they appeared
shocked to learn that he had written about
violence toward others. They said they knew
he had hinted at ideas about suicide, but not
about homicide.
School records indicate that an interpreter
was provided (sometimes this was Chos sis-
ter) during meetings that involved the par-
ents, as is the policy and required by law.
HIGH SCHOOL YEARS
n fall of 1999, Cho began high school at
Centreville High School. The following year
a new school, Westfield High School, opened to
accommodate the population growth in that
part of Fairfax County. Cho was assigned
there for his remaining 3 years. About 1
month after classes began at Westfield, one of
Chos teachers reported to the guidance office
that Chos speech was barely audible and he
did not respond in complete sentences. The
teacher wrote that he was not verbally inter-
active at all and was shy and shut down.
There was practically no communication with
teachers or peers. Those failings aside, teach-
ers also praised Cho for his qualities as a stu-
dent. He achieved high grades, was always on
time for class, and was diligent in submitting
well-done homework assignments. Other than
failing to speak, he did not exhibit any other
unusual behaviors and did not cause prob-
lems. When the teacher asked Cho if he would
like help with communicating, he nodded yes.
The guidance counselors asked Cho whether
he had ever received mental health or special
education assistance in middle school or in his
freshman year (at the previous high school),
and he reportedly indicated (untruthfully)
that he had not.
Chos situation was brought before Westfields
Screening Committee on October 25, 2000, for
evaluation to determine if he required special
education accommodations. Federal law
requires that schools receiving federal funding
enable children with disabilities to learn in
the least restrictive environment and to be
mainstreamed in classrooms. Provisions are made
for special services or accommodations after a core
evaluation involving a battery of tests is given to
diagnose the problems and to guide the school in
preparing an Individualized Education Plan
(IEP). The high school conducted a special as-
sessment to rule out autism as an underlying fac-
tor. Cho also was evaluated in the following
domains:
Psychological
Sociocultural
Educational
Speech/Language
Hearing Screening
Medical
Vision
As part of the assessment process, school person-
nel met with Chos parents to find out more about
his history and to explain the assessment process.
Mrs. Cho expressed concern about how her son
would fare later in college given the transition
required and his poor social skills. She noted that
her son was receiving counseling and gave per-
mission for the school to contact her sons thera-
pist. The therapist, in turn, was encouraged by
the fact that the school would be tracking Chos
progress. The committee determined that Cho was
eligible for the Special Education Program for
Emotional Disabilities and Speech and Language.
Mr. and Mrs. Cho were receptive to receiving help
for him and so was his older sister who was in col-
lege and with whom he had a good relationship.
The parents and sister continued to be in contact
with the school; Sun usually served as interpreter.
Special accommodations were made to help Cho
succeed in class without frustration or intimida-
tion. The school developed an IEP, as required by
law that was effective in January 2001. The IEP
listed two curriculum and classroom accommoda-
tions and modifications: modification for oral
presentations, as needed, and modified grading
scale for oral or group participation. In-school lan-
guage therapy was recommended as well, but Cho
only received that service once a month for 50
minutes. His art therapist, who reached out to a
few teachers and others at the school with
I
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
37
questions or concerns, said she asked why the
language therapy was so limited. The school
responded that it was reluctant to pull him
out of class for this special service because
this would interrupt his academic work or
negatively impact his grades. Besides, the
primary diagnosis was selective mutism, not
problems with the mechanics of speaking or
an inability to function in English.
Cho was encouraged to join a club and to stay
after school for help from teachers. He was
permitted to eat lunch alone and to provide
verbal responses in private sessions with
teachers rather than in front of the whole
class where his manner of speaking and
accent sometimes drew derision from peers.
With this arrangement, Chos grades were
excellent. He had advanced placement and
honors classes. However, his voice was liter-
ally inaudible in class, and he would only
whisper if pushed (an observation consistent
with his behavior later in college). In written
responses, at times, his thinking appeared
confused and his sentence structure was not
fluent. Indeed, his guidance counselor raised
the question to the panel: Why did he change
his major to English at Tech? Why did this
student, whose forte appeared to be science
and math, switch to humanities?
After the Virginia Tech murders, some news-
papers reported that Cho was the subject of
bullying. The panel could not confirm whether
or not he was bullied or threatened. His fam-
ily said that he never mentioned being the
target of threats or intimidating messages,
but then neither did he routinely discuss any
details about school or the events of his day.
His guidance counselor had no records of bul-
lying or harassment complaints.
Nearly all students experience some level of
bullying in schools today. Much of this behav-
ior occurs behind the scenes or off school
groundsand often electronically, through
instant messaging, communications on
MySpace and, to a lesser extent, on Facebook,
a website used by older teenagers. Chos high
school counselor could not say whether bullying
might have occurred before or after school, as
suggested by other unconfirmed sources.
It would be reasonable, however, to assume that
Cho was a victim of some bullying, though to what
extent and how much above the norm is not
known. His sister said that both of them were sub-
jected to a certain level of harassment when they
first came to the United States and throughout
their school years, but she indicated that it was
neither particularly threatening nor ongoing.
In the eleventh grade, Chos weekly sessions at
the mental health center came to an end because
there was a gradual, if slight, improvement over
the years and he resisted continuing, according to
his parents and therapist There is nothing wrong
with me. Why do I have to go? he complained to
his parents. Mr. and Mrs. Cho were not happy
that their son chose to discontinue treatment, but
he was turning 18 the following month and legally
he could make that decision.
Cho took upper level science and math courses
and spent 3 to 4 hours a day on homework. He
earned high marks and finished high school with
a grade point average of 3.52 in an honors pro-
gram. That GPA, along with his SAT scores (540
for verbal and 620 for math registered in the 2002
testing year) were the basis for his acceptance at
Virginia Tech. What the admissions staff at Vir-
ginia Tech did not see were the special accommo-
dations that propped up Cho and his grades.
Those scores reflected Chos knowledge and intel-
ligence, but they did not reflect another compo-
nent of grades: class participation. Since that
aspect of grading was substantially modified for
Cho due to the legally mandated accommodations
for his emotional disability, his grades appeared
higher than they otherwise would have been.
When his guidance counselor talked to Cho and
his family about college, she strongly recom-
mended they send him to a small school close to
home where he could more easily make the transi-
tion to college life. She cautioned that Virginia
Tech was too large. However, Cho appeared very
self-directed and independent in his decision. He
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
38
chose Virginia Tech, which had been his goal
for some time. He applied and was accepted.
Virginia Tech does not require an essay or let-
ters of recommendation in the freshman
application package and does not conduct per-
sonal interviews. Acceptance decisions at Vir-
ginia Tech are based primarily on grades and
SAT scores, though demographics, interests,
and some intangibles are also considered. An
essay about oneself is optional. Cho included a
short writing about rock climbing in his appli-
cation, which was written in the first person
and spoke about human potential that often
cannot be achieved because of self-doubt.
Before Cho left high school, the guidance
counselor made sure that Cho had the name
and contact information of a school district
resource who Cho could call if he encountered
problems at college. As is now known, Cho
never sought that help while at Virginia Tech.
As Cho looked to the fall of 2003, he was pre-
paring to leave home for the first time and
enter an environment where he knew no one.
He was not on any medication for anxiety or
depression, had stopped counseling, and no
longer had special accommodations for his
selective mutism. Neither Cho nor his high
school revealed that he had been receiving
special education services as an emotionally
disabled student, so no one at the university
ever became aware of these pre-existing condi-
tions.
There is a standard cover page that accompa-
nied Chos transcripts to Virginia Tech called
Pupil Permanent Record, Category 1. The
page lists all the types of student records,
whether they include information from ele-
mentary, middle, or high school, and how long
they are to be retained. The lower right corner
of the page has a section marked The Student
Scholastic Record under which are boxes to
be checked as they apply. The first six boxes
are Clinic, Cumulative, Discipline, Due Proc-
ess, Law Enforcement, and Legal. Only the
first two were checked, indicating Cho had no
records pertaining to discipline or legal prob-
lems. Then, there is a subheading labeled Special
Services Files where six additional boxes are pre-
sented: Contract Services, ESL, 504 Plan, Gifted
and Talented, Homebound, and Special Educa-
tion. Only the ESL box is checked, even though
Cho had special education services. The special
education services box was not checked.
As the panel reviewed Chos mental health
records and conducted interviews with persons
who had provided psychiatric and counseling ser-
vices to Cho throughout his public school career, it
became evident that critical records from one pub-
lic institution are not necessarily transferred to
the next as a person matures and enters into new
stages of development. What are the rules regard-
ing the release of special education records
between, for example, high schools and colleges?
It is common practice to require students entering
a new school, college, or university to present
records of immunization. Why not records of seri-
ous emotional or mental problem too? For that
matter, why not records of all communicable dis-
eases?
The answer is obvious: personal privacy. And
while the panel respects this answer, it is impor-
tant to examine the extent to which such informa-
tion is altogether banned or could be released at
the institutions discretion. No one wants to stig-
matize a person or deny her or him opportunities
because of mental or physical disability. Still,
there are issues of public safety. That is why
immunization records must be submitted to each
new institution. But there are other significant
threats facing students beyond measles, mumps,
or polio.
The panel asked its legal counsel to review the
laws pertaining to special education records and
the release of that information, specifically as ad-
dressed in FERPA and the Americans with Dis-
abilities Act (ADA). Although FERPA generally
allows secondary schools to disclose educational
records (including special education records) to a
university, federal disability law prohibits univer-
sities from making what is known as a preadmis-
sion inquiry about an applicants disability
status. After admission, however, universities
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
39
may make inquiries on a confidential basis as
to disabilities that may require accommoda-
tion.
It should be noted that the Department of
Educations March 2007 Transition of Stu-
dents with Disabilities to Post Secondary
Education: A Guide for High School Educa-
tors clarifies that a high school student has
no obligation to inform an institution of post
secondary education that he or she has a dis-
ability; however, if the student wants an aca-
demic adjustment, the student must identify
himself or herself as having a disability. Cho
did not seek any accommodations from Vir-
ginia Tech. The disclosure of a disability is
always voluntary.
It is a more subtle question whether Fairfax
County Public Schools would have had to
remove any indication of special education
status or accommodation from Chos tran-
script or grade reports as part of his college
application.
Because this issue is of such great importance
and because much more study is needed, the
panel does not make a recommendation here.
But the panel hopes that this issue begins to
be debated fully in the public realm. Perhaps
students should be required to submit records
of emotional or mental disturbance and any
communicable diseases after they have been
admitted but before they enroll at a college or
university, with assurance that the records
will not be accessed unless the institutions
threat assessment team (by whatever name it
is known) judges a student to pose a potential
threat to self or others.
Or perhaps an institution whose threat
assessment team determines that a student is
a danger to self or others should promptly con-
tact the students family or high school, inform
them of the assessment, and inquire as to a
previous history of emotional or mental dis-
turbance.
This much is clear: information critical to pub-
lic safety should not stay behind as a person
moves from school to school. Students may
start fresh in college, but their history may
well remain relevant. Maybe there really should
be some form of "permanent record."
Key Findings of Chos School Years
Both the family and the schools recognized
that Chos problem was not merely introver-
sion and that Cho needed therapy to help with
extreme social anxiety, as well as accultura-
tion and communication.
A depressive phase in the second half of
eighth grade led to full blown depression and
thoughts of suicide and homicide precipitated
by the Columbine shooting. Cho received
timely psychiatric assessment and interven-
tion (prescription of Paroxetine and continued
therapy). This episode abated within a year,
and medications were discontinued.
Transportation problems interfered with Chos
involvement with sports and extracurricular
activities, which may have increased his isola-
tion.
Intervention for a child suffering from mental
illness reduces the burden of illness as well as
the risk for severe outcomes such as violence
and suicide, as it did for Cho during his pre-
college years.
During his high school years, Cho was identi-
fied as having special educational needs. His
identification as a special education student
within the first 9 weeks of enrollment in a
new high school and the accommodations ac-
corded him as part of his Individualized Edu-
cational Plan led to a high degree of academic
success. Indeed, his high school guidance
counselor felt that his high school career was
a success. With regard to his social skills,
however, his progress was minimal at best.
Clearly, Cho appeared to be at high risk, as
withdrawn and inhibited behavior confers
risk. This risk seemed mitigated by the inter-
ventions and accommodations put in place by
the school. This risk also was reduced by in-
volved and concerned parents who were par-
ticular in following through with weekly ther-
apy. This risk was further mitigated by effec-
tive therapy that allowed expression (through
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
40
art therapy) of underlying feelings of
inadequacy. These factors as well as an
above-average performance in school (but-
tressed by accommodations) lessened his
frustration and anger.
The school that Cho attended played an
important part in reducing the possibility
of severe regression in his functioning.
The school worked closely with Chos par-
ents and sister. There was coordination
between the school and the therapist and
the psychiatrist who were treating Cho.
These positive influences ended when Cho
graduated from high school. His multi-
faceted support system then disappeared
leaving a huge void.
COLLEGE YEARS
n August of 2003, Cho began classes at
Virginia Tech as a Business Information
Technology major. Mr. and Mrs. Cho were
concerned about his move away from home
and the stress of the new environment, espe-
cially when they learned he was unhappy with
his roommate. His parents visited him every
weekend on Sundays during that first semes-
ter, which was a major time commitment since
they both worked the other 6 days of the week.
They noted that the dorm room trash can was
full of beer cans (allegedly, from the interview
with Chos parents, the roommate was drink-
ing) and the room was quite dirty. Cho, in con-
trast, had kept his room neat at home and had
good hygiene. He requested a room changea
move that his parents and sister saw as a
positive sign that he was being proactive and
taking care of his own affairs. It seemed as
though college was working out for him be-
cause he seemed excited about it.
Cho settled in, got his room changed by the
beginning of the second semester, and seemed
to be adjusting. Parental visits became less
frequent. According to a routine they estab-
lished, every Sunday night he spoke with his
parents by telephone who always asked how
he was doing and whether he needed any-
thing, including money. Mr. and Mrs. Cho said
that he never asked for extra money and would
not accept any. He was very mindful of the fam-
ilys financial situation and lived frugally. He
would not buy things even though his parents
encouraged him occasionally to purchase new
clothes or other items. They reported that he did
not appear envious or angry about anything.
During his freshman year, Cho took courses in
biology, math, communications, political science,
business information systems, and introduction to
poetry. His grades overall were good, and he
ended the year with a GPA of 3.00.
Chos sophomore year (20042005) brought some
changes. Cho made arrangements to share the
rent on a condominium with a senior at Virginia
Tech who worked long hours and was rarely
home. His courses that fall leaned more heavily
toward science and math. His grades slipped that
term. At the same time, he became enthusiastic
about writing and decided he would switch his
major to English beginning the fall semester of
2005. It is unclear why he made this choice as he
disliked using words in school or at home. More-
over, English had not been one of his strongest
subjects in high school.
The answer may be found in an exchange of
e-mails that Cho had with then-Chair of the Eng-
lish Department, Dr. Lucinda Roy. Cho had taken
one of her poetry classes, a large group, entry-
level course the previous semester. On Saturday,
November 6, 2004, he wrote I was in your poetry
class last semester, and I remember you talking
about the books you published. Im looking for a
publisher to submit my novelI was just wonder-
ing if you know of a lot of publishers or agents or
if you have a good connection with them. He went
on, My novel is relative[ly] shortsort of like
Tom Sawyer except that its really silly and
pathetic depending on how you look at it. Dr.
Roys first e-mail back said: Could you send me
your name? You forgot to sign your note. Seung
Cho, he wrote. Dr. Roy then recommended two
resource books and gave him tips on finding liter-
ary agents. She also advised, If you havent yet
I
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
41
taken a creative writing (fiction) courseyou
should consider doing so.
University personnel explained to the panel
that Virginia Techs process for changing
majors relies on advisors who serve to help
ensure that students are taking the right
number of credits and courses to meet the
requirements of their major and to graduate.
They do not generally offer counsel on
whether a student is making a wise move or
examine the reasons behind their class
choices. In any given year at Virginia Tech,
many students change majors. Over 40 per-
cent of the student body changes their major
after the first year or two. Thus this change is
not abnormal and not a red flag.
Cho seemed to enjoy the idea of writing, espe-
cially poetry. His sister noticed that he would
bring home stacks of books on literature and
poetry and books on how to become a writer.
Writing seemed to have become a passion, and
his family was thrilled that he found some-
thing he could be truly excited about. He
would spend hours at his computer writing,
but when his sister asked to see his work, he
would refuse. On one rare occasion, she did
get to read a story he wrote about a boy and
his imaginary friend, which she thought was
somewhat strange, but nothing too odd.
Chos parents never read his compositions,
both because he did not offer to show them
and because they did not read English, at
least not well.
Cho took three English courses in the spring
of 2005, plus an economics course, and an
introductory psychology course. He did not do
particularly well, especially in the literature
courses. One of his English professors gave
him a D-, another, a C+. He earned a B+ in
Introduction to Critical Reading, but also
withdrew from the economics class, thus earn-
ing only 12 credits and registering a 2.32 for
the semester.
Late that sophomore year, in his presence,
Chos sister chanced upon a rejection letter
from a New York publishing house on Chos desk
at home. He had submitted a topic for a book
describing the books outline. She encouraged him
to continue to write and learn saying that all
writers have to work at their craft for a long time
before they are published and that he was just at
the beginning and not to lose heart.
While living in the off-campus condominium, Cho
became convinced that he had mite bites (based
on searches he did on the Internet). He went to a
local doctor who diagnosed it as severe acne and
put him on medication. Other than followup
appointments for his acne at home and at the
Shiffert Medical Center at Virginia Tech (he con-
tinued to believe mites were the problem), he did
not have regular appointments with general prac-
titioners, specialists, psychiatrists, or counselors
in his hometown during his entire college tenure.
His family reported that he came home for all his
breaks and would spend the time writing, reading,
playing basketball, and riding his bikealone.
Storm Clouds Gathering, Fall 2005 The fall
semester of Chos junior year (2005) was a pivotal
time. From that point forward, Cho would become
known to a growing number of students and fac-
ulty not only for his extremely withdrawn person-
ality and complete lack of interest in responding
to others in and out of the classroom, but for hos-
tile, even violent writings along with threatening
behavior.
He registered for French and four English
courses, one of which was Creative Writing:
Poetry, taught by Nikki Giovanni. It would seem
he selected this course on the basis of Dr. Roys
advice to him the previous fall. His sister began
noticing some subtle changes: he was not writing
as much in his junior year and he seemed more
withdrawn. The family wondered whether he was
getting anxious about the future and what he
would do after graduation. His father wanted him
to go to graduate school, but Cho indicated he did
not want to continue with academics after he
graduated. His parents then offered to help him
find a job after graduation, but he refused.
Cho had moved back to the dormitories that
semester. He had a roommate and two suitemates
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
42
who lived in another room connected by a
bathrooma typical layout in the residence
halls. The panel interviewed his roommate
and one suitemate who related some events
from that year. They described Cho in the
same way as he is described throughout this
report: very quiet, short responses to ques-
tions, and rarely initiating any communica-
tion. At the beginning of the school year, the
roommate and the other suitemates took Cho
to several parties. He would always end up
sitting in the corner by himself. One time they
all went back to a female students room. Cho
took out a knife (lock blade, not real large)
and started stabbing the carpet. They stopped
taking him out with them after that incident.
The three suitemates would invite Cho to eat
with them at the beginning of the year, but he
would never talk so they stopped asking. They
observed him eating alone in the dining hall
or lounge. The roommate asked Cho who he
hung out with and Cho said nobody. He
would see him sometimes at the gym playing
basketball by himself or working out.
Chos roommate never saw him play video
games. He would get movies from the library
and watch them on his laptop. The roommate
never saw what they were, but they always
seemed dark. Cho would listen to and down-
load heavy metal music. Someone wrote heavy
metal lyrics on the walls of their suite in the
fall, and then in the halls in the spring. Sev-
eral of the students believed Cho was respon-
sible because the words were similar to the
lyrics Cho posted on Facebook.
Several times when the suitemates came in
the room, it smelled as though Cho had been
burning something. One time they found
burnt pages under a sofa cushion. Cho would
go to different lounges and call one of the
suitemates on the phone. He would identify
himself as question markChos twin
brotherand ask to speak with Seung. He
also posted messages to his roommates
Facebook page, identifying himself as Chos
twin. The roommate saw a prescription drug
bottle on his desk. He and the others in the suite
looked it up online and found that it was a
medication for skin fungus.
Chos actions in the poetry class taught by Nikki
Giovanni that semester are widely known and
documented. For the first 6 weeks of class, the
professor put up with Chos lack of cooperation
and disruptive behavior. He wore reflector glasses
and a hat pulled down to obscure his face.
Dr. Giovanni reported to the panel that she would
have to take time away from teaching at the
beginning of each class to ask him to please take
off his hat and please take off his glasses. She
would have to stand beside his desk until he
complied. Then he started wearing a scarf
wrapped around his head, Bedouin-style
according to Professor Giovanni. She felt that he
was trying to bully her.
Cho also was uncooperative in presenting and
changing the pieces that he wrote. He would read
from his desk in a voice that could not be heard.
When Dr. Giovanni would ask him to make
changes, he would present the same thing the fol-
lowing week. One of the papers he read aloud was
very dark, with violent emotions. The paper was
titled So-Called Advanced Creative Writing
Poetry. He was angry because the class had spent
time talking about eating animals instead of
about poetry, so his composition, which he would
later characterize as a satire, spoke of an animal
massacre butcher shop.
In the paper, Cho accused the other students in
the class of eating animals, I dont know which
uncouth, low-life planet you come from but you
disgust me. In fact, you all disgust me. He made
up gruesome quotes from the classmates, then
wrote, You low-life barbarians make me sick to
the stomach that I wanna barf over my new shoes.
If you despicable human beings who are all dis-
graces to [the] human race keep this up, before
you know it you will turn into cannibalseating
little babies, your friends,. I hope yall burn in hell
for mass murdering and eating all those little
animals.
Dr. Giovanni began noticing that fewer students
were attending class, which had never been a
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
43
problem for her before. She asked a student
what was going on and he said, Its the
boyeveryones afraid of him. That was
when she learned that Cho also had been
using his cell phone to take pictures of stu-
dents without permission.
Dr. Giovanni talked to Cho, telling him, I
dont think Im the teacher for you, and
offered to get him into another class. He said
that he did not want to transfer, which sur-
prised her. She contacted the head of the Eng-
lish Department, Dr. Roy, about Cho and
warned that if he were not removed from her
class, she would resign. He was not just a dif-
ficult student, she related, he was not working
at all. Dr. Giovanni was offered security, but
declined saying she did not want him back in
class, period. She saw him once on campus
after that and he just stared at the ground.
Dr. Roy explained to the panel what her
actions were once Dr. Giovanni made her
aware of Chos upsetting behavior. She
remembered Cho from the previous semester
when he took that poetry class she taught (she
had given him a B- in the course). Dr. Roy con-
tacted the Dean of Student Affairs, Tom
Brown, the Cook Counseling Center, and the
College of Liberal Arts with regard to the
objectionable writing that Dr. Giovanni
showed Dr. Roy. She asked to have it evalu-
ated from a psychological point of view and
inquired about whether the picture-taking
might have been against the code of student
conduct.
Dean Brown sent an e-mail message to Dr.
Roy and advised there is no specific policy
related to cell phones in class. But, in Section
2 of the University Policy for Student Life,
item #6 speaks to disruption. This is the dis-
orderly conduct section which reads: Behav-
ior that disrupts or interferes with the orderly
function of the university, disturbs the peace,
or interferes with the performance of the
duties of university personnel. Clearly, the
disruption he caused falls under this policy if
adjudicated.
Dean Brown also said, I talked with a coun-
selorand shared the content of the poem and
she did not pick up on a specific threat. She sug-
gested a referral to Cook during your meeting. I
also spoke with Frances Keene, Judicial Affairs
director and she agrees with your plan. He con-
tinued, I would make it clear to him that any
similar behavior in the future will be referred.
Frances Keene noted in her response to Dean
Brown and Dr. Roy that she was available if Cho
had any further questions about how using his
cell phone in class to take photographs could con-
stitute disorderly conduct. She also wrote, I agree
that the content is inappropriate and alarming
but doesnt contain a threat to anyones immedi-
ate safety (thus, not actionable under the abusive
conduct threats section of the UPSL).
During an interview with the panel, Ms. Keene
related that she would have needed something in
writing to initiate an investigation into the disor-
derly conduct violation, and reported that she
never received anything. The formal request
would have come from the English Department.
Ms. Keene recalled that the concern about Cho
was brought before the universitys Care Team,
of which she is a member, at their regular meet-
ing. The Care Team is comprised of the dean of
Student Affairs, the director of Residence Life, the
head of Judicial Affairs, Student Health, and legal
counsel. Other agencies from the university are
occasionally asked to participate; including the
Womens Center, fraternities and sororities, the
Disability Center, and campus police, though
these agencies are not standing members of the
Team.
At the Care Team meeting, members were advised
of the situation with Cho and that Dr. Roy and Dr.
Giovanni wanted to proceed with a class change to
address the matter. The perception was that the
situation was taken care of and Cho was not dis-
cussed again by the Care Team. The team made
no referrals of Cho to the Cook Counseling Center.
The Care Team did nothing. There were no refer-
rals to the Care Team later that fall semester
when Resident Life, and later, VTPD became
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
44
aware of Chos unwanted communications to
female students and threatening behavior.
Frances Keene said that she received no com-
munications from the female students who
had registered complaints about Cho and that
she learned of those incidents only through
campus police incident reports. However, the
assistant director of Judicial Affairs, Rohsaan
Settle, received an e-mail communication on
December 6 advising her of Chos odd behav-
ior and stalking. Ms. Keene indicated that
it is her offices policy to contact students who
have been threatened and advise them of their
rights, but one of the students stated that she
was never contacted by Judicial Affairs, and
there is no documentation that the others
were contacted. Ms. Keene indicated that she
would have discussed these incidents with the
Care Team at the time the incidents occurred
had she known about them.
Dr. Roy e-mailed Cho and asked him to con-
tact her for a meeting. He responded with an
angry, two-page letter in which he harshly
criticized Dr. Giovanni and her teaching, say-
ing she would cancel class and would not
really instruct, but just have students read
what they wrote and discuss the writings. He
agreed to meet with Dr. Roy and said I know
its all my fault because of my personal-
ityBeing quiet, one would think, would repel
attention but I seem to get more attention
than I want (I can just tell by the way people
stare at me). He said he imagined she was
going to yell at me.
Dr. Roy asked a colleague, Cheryl Ruggiero, to
be present for the meeting with Cho. Ms.
Ruggiero took notes, the transcription of
which provided an exceptionally detailed ac-
count of that session with Cho as did e-mails
from Dr. Roy to appropriate administration
officials after the meeting.
Cho arrived wearing dark sunglasses. He
seemed depressed, lonely, and very troubled.
Dr. Roy assured him she was not going to yell
at him, but discussed the seriousness of what
he wrote and his other actions. He replied that
he was just joking about the writing in
Giovannis class, but agreed that it might have
been perceived differently. Dr. Roy asked him if
he was offended by the class discussion on eating
animals and he said, I wasnt offended. I was just
making fun of itthought it was funny, thought
Id make fun of it. He was asked if he was a vege-
tarian or had religious beliefs about eating meat
or animals; he answered no to both questions.
Ms. Ruggieros transcript mentions that Dr. Roy
proposes alternative of working independently
with herself and Fred DAguiar. The transcript
also notes that Cho doesnt want to lose cred-
itsif not kicked out will stay [I (Ruggiero)
noted some emotion on the words kicked out, a
small spark of anger or resentment]. The tran-
script goes on to document that Lucinda asked if
he would remove his sunglasses. Cho takes a long
time to respond, but he does remove them. It is a
very distressing sight, since his face seems very
naked and blank without them. Its a great relief
to be able to read his face, though there isnt much
there. Dr. Roy asks if taking off the sunglasses
has been terrible for himand says he doesnt
seem like himself, like the student she knew in
the Intro to Poetry class, and she asks if anything
terrible or bad has happened to him. Eventually
Cho answers No.
Twice during the meeting with Cho, Dr. Roy
asked him if he would talk to a counselor. She told
him she had the name of someone, and asked
again if he would consider going. He did not
answer for a while, and then said vaguely, sure.
In her interview with the panel, Dr. Roy stated
that the universitys policy made the situation
difficult. She was obligated to offer Cho an alter-
native that was equivalent to the instruction he
would receive in Giovannis class. Thus, she
offered to tutor him privately. He later agreed.
She told Cho that he would have to meet four
more times and do some writing. As he left the
meeting, Dr. Roy gave him a copy of her book. He
took it and appeared to be crying, she related.
Throughout the deliberations about Chos writing
and behavior and the available options, Dr. Roy
communicated widely with all relevant university
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
45
officers and provided updates on meetings and
decisions. On October 19, 2005, Dr. Roy
e-mailed Zenobia Hikes, Tom Brown, George
Jackson, and Robert Miller with a report on
her meeting with Cho.
Cheryl and I met with the student we
spoke about today. We spoke about 30
minutes. He was very quiet and it took
him long time to respond to question; but
I think he may be willing to work with
me and with Professor Fred DAguiar
rather than continuing in Nikki's
courseh e didn't seem to think that his
poem should have alarmed anyone
[But] he also said he understood why
people assumed from the piece that he
was angry with them. I strongly recom-
mended that he see a counselor, and he
didn't commit to that one way or the
other. Both Cheryl and I are genuinely
concerned about him because he ap-
peared to be very depressedthough of
course only a professional could verify
that.
One month later, Dr. Roy wrote to Associate
Dean Mary Ann Lewis, Liberal Arts & Human
Sciences, who in turn shared it with the dean
of Student Affairs and Ellen Plummer,
Assistant Provost and Director of the Womens
Center. She wrote
He is now meeting regularly with me and
with Fred DAguiar rather than with
Nikki. This has gone reasonably well,
though all of his submissions so far have
been about shooting or harming people
because hes angered by their authority
or by their behavior. Were hoping hell
be able to write inside a different kind of
narrative in the future, and were
encouraging him to do soI have to ad-
mit that Im still very worried about this
student. He still insists on wearing
highly reflective sunglasses and some
responses take several minutes to elicit.
(Im learning patience!) But I am also
impressed by his writing skills, and by
what he knows about poetry when he
opens up a little. I know he is very angry,
however, and I am encouraging him to
see a counselorsomething hes resisted
so far. Please let me and Fred know if
you see a problem with this approach.
For the remainder of the semester, Dr. Roy
focused on William Butler Yeats and Emily Dick-
inson to help him develop empathy toward others
and redirect his writing away from violent
themes. They worked on a poem together where
she went over technical skills. She saw no overt
threats in the writings he did for her. He was stiff,
sad, and seemed deliberately inarticulate, but
gradually he opened up and wrote well. She
repeatedly offered to take him to counseling. She
eventually gave him an A for a grade.
Cho did not go home for Thanksgiving, according
to his roommate and resident advisor, though he
thought that Cho may have gone home for a few
days at Christmas. When Chos parents were
asked about this they indicated that he came
home at every break, but that sometimes he
would have to wait a day or so until their day off
work so they could come pick him up at school.
According a VTPD incident report, on Sunday,
November 27, the police, following a complaint
from a female student who lived on the fourth
floor of West Ambler Johnston, came to Chos
room to talk to him. The roommate went to the
lounge and then returned after the police left. Cho
said want to know why the police were here? He
then related that he had been text messaging a
female student and thought it was a game. He
went to her room wearing sunglasses and a hat
pulled down and said Im question mark. He
said that the student freaked out, and the resi-
dent advisor came out and called the police.
According to the police record, the officer warned
Cho not to bother the female student anymore,
and told him they would refer the case to Judicial
Affairs.
The resident advisor told the panel about Cho,
He was strange and got stranger. She said that
Chos roommate and one of the other suitemates
found a very large knife in Chos desk and dis-
carded it.
On Wednesday, November 30, at 9:45 am, Cho
called Cook Counseling Center and spoke with
Maisha Smith, a licensed professional counselor.
This is the first record of Chos acting upon pro-
fessors advice to seek counseling, and it followed
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
46
the interaction he had had with campus police
three days before. She conducted a telephone
triage to collect the necessary data to evaluate
the level of intervention required. Ms. Smith
has no independent recollection of Cho and
her notes from the triage are missing from
Chos file. A note attached to the electronic
appointment indicates that Cho specifically
requested an appointment with Cathye Betzel,
a licensed clinical psychologist, and indicated
that his professor had spoken with Dr. Betzel.
The appointment was scheduled for December
12 at 2:00 pm, but Cho failed to keep the ap-
pointment. However, he did call Cook Coun-
seling after 4:00 pm that same afternoon and
was again scheduled for telephone triage.
According to the Cook scheduling program
documents, Cho was again triaged by tele-
phone at 4:45 on December 12. This triage
was conducted by Dr. Betzel who has no recol-
lection of the specific content of the brief tri-
age appointment. Written documentation
that would have typically been completed at
that time is missing. The ticket completed to
indicate the type of contact indicates that the
telephone appointment was kept, that no
diagnosis was made (consistent with Cooks
procedure to not make a diagnosis until a
clinical intake interview is completed) and
that no referral was made for follow-up ser-
vices either at Cook or elsewhere. Dr. Betzel
did recall at the time of her interview with the
panel that she had a conversation with Dr.
Roy concerning a student whose name she did
not recall, however the details were so similar
that she believes it was Cho. She recalls that
Dr. Roy was concerned about disturbing writ-
ings submitted by Cho in class, and that Dr.
Roy detailed her plans to meet with the stu-
dent individually. The date of Dr. Betzels con-
sultation with Dr. Roy is unknown and any
written documentation that would typically
have been associated with the consultation is
missing from Chos file.
CHOS HOSPITALIZATION AND
COMMITMENT PROCEEDINGS
(The law pertaining to these proceedings is discussed in
Part B of this chapter.)
n December 12, 2005, the Virginia Tech Po-
lice Department (VTPD) received a complaint
from a female sophomore residing in the East
Campbell residence hall regarding Cho. She knew
Cho through his roommate and suitemate. The
students had attended parties together at the
beginning of the semester and it was at this young
womans room that Cho had produced a knife and
stabbed the carpet. While the student no longer
saw Cho socially, she had received instant mes-
sages and postings to her Facebook page through-
out the semester that she believed were from him.
The messages were not threatening, but, rather,
self-deprecating. She would write back in a posi-
tive tone and inquire if she were responding to
Cho. The reply would be I do not know who I
am. In early December, she found a quote from
Romeo and Juliet written on the white erase
board outside her dorm room. It read:
By a name
I know not how to tell thee who I am
My name, dear saint is hateful to myself
Because it is an enemy to thee
Had I it written, I would tear the word
The young woman shared with her father her con-
cerns about the communications that she believed
were from Cho. The father spoke with his friend,
the chief of police for Christiansburg, who advised
that the campus police should be informed.
The following day, December 13, a campus police
officer met with Cho and instructed him to have
no further contact with the young woman. She did
not file criminal charges. No one spoke with her
regarding her right to file a complaint with Judi-
cial Affairs. Records document that there were
multiple e-mail communications regarding the
incident among Virginia Tech residential staff, the
residence life administrator on call, and the presi-
dents & upper quad area coordinator, the director
of Residence Life, and the assistant director of
Judicial Affairs. The matter was not, however,
O
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
47
brought before the Virginia Tech multi-
disciplinary Care Team.
Following the visit from the police, Cho sent
an instant message to one of his suitemates
stating I might as well kill myself. The
suitemate reported the communication to the
VTPD.
Police officers returned around 7:00 p.m. that
same day to interview Cho again in his dorm
room. The suitemate was not present, but they
spoke to Chos roommate out of his presence.
The officers took Cho to VTPD for assessment,
and a pre-screen evaluation was conducted
there at 8:15 p.m. by a licensed clinical social
worker for New River Valley Community
Services Board (CSB). The pre-screener inter-
viewed Cho and the police officer, and then
spoke with both Chos roommate and a suite-
mate by phone. She recorded her findings on a
five-page Uniform Pre-Admission Screening
Form, checking the findings boxes indicating
that Cho was mentally ill, was an imminent
danger to self or others, and was not willing to
be treated voluntarily. She recommended
involuntary hospitalization and indicated that
the CSB could assist with treatment and dis-
charge planning. She located a psychiatric
bed, as required by state law at St. Albans
Behavioral Health Center of the Carilion New
River Valley Medical Center (St. Albans) and
contacted the magistrate by phone to request
that a temporary detention order (TDO) be
issued.
The magistrate considered the pre-screen
findings and issued a TDO at 10:12 p.m. Po-
lice officers transported Cho to St. Albans
where he was admitted at 11:00 p.m. Cho did
not speak at all with the officer during the trip
to the hospital. He was noted to be cooperative
with the admitting process. The diagnosis on
the admission orders was Mood Disorder,
NOS [non specific]. On the Carilion Health
Services screening form for the potential for
violence, it was marked that Cho denied any
prior history of violent behavior, but that he
did have access to a firearm. (The panel
inquired about this, and checking the box for fire-
arm access may have been an error.) He was on no
medication at the time of admission, but Ativan
was prescribed for anxiety, as needed. One milli-
gram of Ativan was administered at 11:40 p.m.
(The records do not show that he ever received
another dose.) Cho passed an uneventful night
according to the nursing notes.
On the morning of December 14, at approximately
6:30 a.m., the Clinical Support Representative for
St. Albans met with Cho to give him information
about the mental health hearing. Around 7:00
a.m., the representative escorted Cho to meet with
a licensed clinical psychologist, who conducted an
independent evaluation of Cho pursuant to
Virginia law.
The independent evaluator reported to the panel
that he reviewed the prescreening report, but that
due to the early hour, there were no hospital
records available for his review. He did not speak
with the designated attending psychiatrist who
had not yet seen Cho. The evaluator has no spe-
cific recollection, but believes that the independ-
ent evaluation took approximately 15 minutes.
The evaluator completed the evaluation form cer-
tifying his findings that Cho is mentally ill; that
he does not present an imminent danger to
(himself/others), or is not substantially unable to
care for himself, as a result of mental illness; and
that he does not require involuntary hospitaliza-
tion. The independent evaluator did not attend
the commitment hearing; however, both counsel
for Cho and the special justice signed off on the
form certifying his findings.
Shortly before the commitment hearing, the at-
tending psychiatrist at St. Albans evaluated Cho.
When he was interviewed by the panel, the psy-
chiatrist did not recall anything remarkable about
Cho, other than that he was extremely quiet. The
psychiatrist did not discern dangerousness in Cho,
and, as noted, his assessment did not differ from
that of the independent evaluatorthat Cho was
not a danger to himself or others. He suggested
that Cho be treated on an outpatient basis with
counseling. No medications were prescribed, and
no primary diagnosis was made.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
48
The psychiatrists conclusion was based in
part on Chos denying any drug or alcohol
problems or any previous mental health
treatment. The psychiatrist acknowledged
that he did not gather any collateral informa-
tion or information to refute the data obtained
by the pre-screener on the basis of which the
commitment was obtained. He indicated that
this is standard practice and that privacy laws
impede the gathering of collateral informa-
tion. (Chapter V discusses these information
privacy laws in detail.) The psychiatrist also
said that the time it takes to gather collateral
information is prohibitive in terms of existing
resources.
Freer access to clinical information among
agencies is imperative so that a rational plan
for treatment can be developed. As for the
relationship between the independent evalua-
tor and the staff psychiatrist, they rarely see
each other and they function independently.
The role of the independent evaluator is to
provide information to the court and the job of
the attending psychiatrist is to provide clinical
care for the patient.
As for counseling services at Virginia Tech
and the other area universities from which St.
Albans Hospital receives patients, according
to the psychiatrist they are all stretched for
mental health resources. The lack of outpa-
tient providers who can develop a post-
discharge treatment plan of substance is a
major flaw in the current system. The lack of
services is common in both the public and the
private outpatient sectors.
The psychiatrist noted his recommendation
for outpatient counseling on the Initial Con-
sent Form for TDO Admissions. The clinical
support representative then escorted Cho and
other TDO patients to meet with their attor-
ney prior to their hearings. There were four
hearings that morning, and the attorney has
no specific recollection of Cho.
A special justice designated by the Circuit
Court of Montgomery County presided over
the commitment hearing for Cho held shortly
after 11:00 a.m. on December 14. Neither Chos
suitemate nor his roommate nor the detaining
police officer nor the pre-screener nor the inde-
pendent evaluator nor the attending psychiatrist
attended the hearing. The prescreening report
was read into the record by Chos attorney. The
special justice reviewed the independent evalua-
tion form completed by the independent evaluator
and the treating psychiatrists recommendation.
He heard evidence from Cho. The special justice
ruled that Cho presents an imminent danger to
himself as a result of mental illness and ordered
O-P (outpatient treatment) to follow all rec-
ommended treatments.
The clinical support representative (CSR) con-
tacted Cook Counseling Center at Virginia Tech to
make an appointment for Cho. The Cook Counsel-
ing Center required that Cho be put on the phone
(a practice begun shortly before this hearing
according to the CSR) to make the appointment,
which he did. The appointment was scheduled for
3:00 p.m. that afternoon, December 14. The CSR
does not recall whether this phone call was made
prior to or following the hearing.
The clinical support representative recalls making
his customary phone call to New River Valley CSB
to advise them of the outcome of the mornings
hearings. It was not the hospitals practice at that
time to send copies of the orders from the com-
mitment hearings.
Due to the rapidly approaching outpatient
appointment for Cho, the CSR urged the treating
psychiatrist to expedite the dictation and tran-
scription of his discharge summary. It was tran-
scribed shortly before noon and the physical
evaluation findings and recommendation about an
hour later. The clinical support representative
recalls faxing the records to Cook Counseling Cen-
ter, but he did not place a copy of the transmittal
confirmation in the hospital records. Cook Coun-
seling Center, however, has no record of having
received any hospital records until January 2006.
The physical evaluation report indicated that Cho
was to be treated by the psychiatrist at St. Albans
and hopefully have some intervention in therapy
for treatment of his mood disorder. The discharge
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
49
summary, which was not part of the records
received by the panel from Cook Counseling
Center, indicated followup and aftercare to be
arranged with counseling center at Virginia
Tech. Medications none.
Cho was discharged from St. Albans at 2:00
p.m. on December 14. No one the panel inter-
viewed could say how Cho got back to campus.
However, the electronic scheduling program at
the Cook Counseling Center indicates that
Cho kept his appointment that day at 3:00
p.m. He was triaged again, this time face-to-
face, but no diagnosis was given. The triage
report is missing (as well as those from his
two prior phone triages), and the counselor
who performed the triage has no independent
recollection of Cho. It is her standard practice
to complete appropriate forms and write a
note to document critical information, recom-
mendations, and plans for followup.
It is unclear why Cho would have been triaged
for a third time rather than receiving a treat-
ment session at his afternoon appointment
following release from St. Albans. The Colle-
giate Times had run an article at the begin-
ning of the fall semester expressing concern
about the diminished services provided by the
counseling center and the temporary loss of
its only psychiatrist.
It was the policy of the Cook Counseling Cen-
ter to allow patients to decide whether to
make a followup appointment. According to
the existing Cook Counseling Center records,
none was ever scheduled by Cho. Because
Cook Counseling Center had accepted Cho as
a voluntary patient, no notice was given to the
CSB, the court, St. Albans, or Virginia Tech
officials that Cho never returned to Cook
Counseling Center.
AFTER HOSPITALIZATION
hos family did not realize what was hap-
pening with him at Blacksburg that fall
2005 semester: his dark writings, stalking,
and other odd and unsettling behavior that
worried roommates, resident advisors, teach-
ers and eventually, campus police. They were un-
aware that their son had been committed for a
time to St. Albans Hospital or that he had ap-
peared in court before a special justice. This is
corroborated by documents and interviews relat-
ing that Cho refused to notify his parents when
campus police responded to his threat of suicide.
The university did not inform the parents either.
According to Virginia Tech records, there was a
home town doctor or counselor who Cho could
see when he was home. The panel did not discover
what led to this assumption. However, it is known
that the university did not contact the family to
ascertain the veracity of home town followup for
counseling and medication management.
When Chos parents were asked what they would
have done if they had heard from the college about
the professors, roommates, and female students
complaints, their response was, We would have
taken him home and made him miss a semester to
get this looked at but we just did not know
about anything being wrong. From their history
during the high school years, we do know that
they were dedicated to getting him to therapy con-
sistently and also consented to psychopharmacol-
ogy when the need arose.
More Problems, Spring 2006 The trend of dis-
turbing themes continued to be apparent in many
of Chos writings, along with his selective mutism.
Robert Hicok had Cho in his Fiction Workshop
class that semester. Hicok described his class as a
mid-level fiction course with about 20 students.
He told the panel that there was no participation
from Cho and that Chos stories and work were
violent. He said Cho was a very cogent writer, but
his creativity was not that good. Cho was open to
suggestions and he made some edits, but he was
not very unique in his writing. The combination
of the content of Chos stories and his not talking
raised red flags for Hicok. He consulted with Dr.
Roy, but then decided to keep Cho in the class and
just deal with him. Hicok scheduled two meetings
with Cho, but he did not show up, and Hicok
never saw Cho again after the semester ended.
Cho received a D+ in this class.
C
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
50
Professor Hicok shared none of Chos writings
with the panel. However, based on a question
to a panel member by a reporter, further in-
quiry was made as this report was about to go
to press. Several writings by Cho in Hicoks
class were produced, one of which is of par-
ticular significance. It tells the story of a
morning in the life of Bud who gets out of bed
unusually earlyputs on his black jeans, a
strappy black vest with many pockets, a black
hat, a large dark sunglasses [sic] and a flimsy
jacket. At school he observes students
strut inside smiling, laughing, embracing each
other.A few eyes glance at Bud but without
the glint of recognition. I hate this! I hate all
these frauds! I hate my life.This is it.This
is when you damn people die with me. He
enters the nearly empty halls and goes to an
arbitrary classroom. Inside (e)veryone is
smiling and laughing as if theyre in heaven-
on-earth, something magical and enchanting
about all the peoples intrinsic nature that
Bud will never experience. He breaks away
and runs to the bathroom I cant do this.I
have no moral right. The story continues by
relating that he is approached by a gothic
girl. He tells her Im nothing. Im a loser. I
cant do anything. I was going to kill every god
damn person in this damn school, swear to
god I was, but Icouldnt. I just couldnt.
Damn it I hate myself! He and the gothic
girl drive to her home in a stolen car. If I get
stopped by a cop my life will be forever over. A
stolen car, two hand guns, and a sawed off
shotgun. At her house, she
retrieves a .8 caliber automatic rifle and a
M16 machine gun. The story concludes with
the line You and me. We can fight to claim
our deserving throne.
Cho encountered problems in another English
class that semester, Technical Writing, taught
by Carl Bean. The professor told the panel
that Cho was always very quiet, always wore
his cap pulled down, and spoke extremely
softly. Bean opined that this was his power.
By speaking so softly, he manipulated people
into feeling sorry for him and his fellow stu-
dents would allow him to get credit for group pro-
jects without having worked on them. Bean noted
that Cho derived satisfaction from learning how
to play the gamedo as little as he needed to do
to get by. This profile of Cho stands in contrast to
the profile of a pitiable, emotionally disabled
young man, but it may in fact represent a true
picture of the other side of Chothe one that
murdered 32 people.
Bean allowed that Cho was very intelligent. He
could write with technical proficiency and could
read well. However, his creative writing skills
were limited and his command of the English lan-
guage was very impoverished. He had trouble
with verb tenses and use of articles. On two or
three occasions early in the semester, Bean had
spoken to Cho after class regarding the fact that
he was not participating orally nor working col-
laboratively on group assignments. By late March
or early April, the class was given a writing
assignment to do a technical essay about a subject
within their major. Cho suggested George Wash-
ington and the American Revolution, but Bean
advised him that this was not within his major.
Cho next suggested the April 1960 revolution in
Koreaagain rejected because the topic was not
in his major. Cho then decided to write an objec-
tive real-time experience based on Macbeth and
corresponding to serial killings.
On April 17, 2006, one school year prior to the
shooting to the day (because it was also a Mon-
day), Bean asked Cho to stay after class again.
The professor explained to Cho that his work was
not satisfactory and that his topic was not accept-
able. He recommended that Cho drop the class
and that he would recommend that a late drop be
permitted. Cho never said a word, just stared at
him. Then, without invitation, Cho followed Bean
to his office. The professor offered for him to sit
down, but Cho refused and proceeded to argue
loudly that he did not want to drop the class. Bean
was surprised because he had never heard Cho
speak like that before nor engage in that type of
conduct. He asked Cho to leave his office and
return when he had better control of himself. Cho
left and subsequently sent an e-mail advising that
he had dropped the course.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
51
Bean did not discuss the matter with Dr. Roy
and he was not aware that Nikki Giovanni
had encountered problems with Cho the prior
semester. After the massacre of April 16, it
was discovered that Cho had mailed a letter to
the English Department on that same day.
Bean stated he knew Cho was antisocial,
manipulative, and intelligent. Cho, he said,
had obviously researched Bean after drop-
ping Beans course, because in the April 16
letter Cho wrote numerous times that Bean
went holocaust on me. Bean has a great
interest in the Holocaust.
Fall 2006 Cho enrolled in Professor Ed
Falcos playwriting workshop in the fall
semester. During the first class when each
student was asked to introduce him/herself to
the class, Cho got up and left before his turn.
When he returned for the second class, Profes-
sor Falco informed him that he would have to
participate; Cho did not respond. In his inter-
view with the panel, Professor Falco described
Chos writing as juvenile with some pieces
venting anger.
Post April 16, 2007 students from this class
were quoted in the campus newspaper as say-
ing that some class members had joked that
they were waiting for Cho to do something.
One student reportedly had told a friend that
Cho was the kind of guy who might go on a
rampage killing.
According to an article in the August 10, 2007
edition of The Roanoke Times, Professor Falco,
director of Virginia Techs creative writing
program, recently proposed and participated
in the drafting of written guidelines for deal-
ing with students who submit disturbing and
violent work. The guidelines suggest that fac-
ulty concerned about a students writing pur-
sue a series of actions including speaking to
the student, encouraging the student to seek
counseling, and involving university adminis-
trators.
Cho also took a class called Contemporary
Horror in the fall of 2006. His final exam
paper which appears to analyze a horror film
is reasonable and cogent. The professor awarded
Cho a B for the course.
Chos senior year roommate explained to the
panel that he tried speaking to Cho at the begin-
ning of the semester, but Cho barely responded. I
hardly knew the guy; we just slept in the same
room. Cho went to bed early and got up early, so
his roommate just left him alone and gave him his
space. The only activities Cho engaged in were
studying, sleeping, and downloading music. He
never saw him play a video game, which he
thought strange since he and most other students
play them. One of the suitemates mentioned that
he saw Cho working out at McCommis Hall and
saw him return to the room from time to time in
workout attire. Cho kept his side of the room very
neat. Nothing appeared to be abnormalno
knives, guns, chains, etc. The only reading mate-
rial the roommate saw on Chos side was a paper-
back copy of the New Testament, which he
thought may have been for a class. (Cho took a
course in the spring 2007 semester: The Bible as
Literature.)
The resident advisor for the section of Harper Hall
where Cho resided had been forewarned by the
previous years RA that there were issues with
Cho. She knew about his unwanted advances to-
ward female students and that he was suspected
of writing violent song lyrics on the dorm walls
that also were posted on his web site. However,
she did not encounter a single problem with him.
That fall semester, Cho enrolled in Professor
Norris Advanced Fiction Workshopa small class
of only about 10 students. Cho had taken one of
her classes the previous spring, on contemporary
fiction, so she knew how little he participated in
class. Norris realized that the workshop class
would be a problem for Cho because there would
be discussions and readings. Cho appeared in
class with a ball cap pulled low and making no eye
contact. Norris checked with the deans office to
see if it was safeif Cho was okayand she
asked to have someone intervene on his behalf.
The English Department did not know about
Chos dealings with campus police and the
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
52
communications generated from Residence
Life about his stalking behavior.
Norris told Cho that he had to come see her if
he was going to able to make it through this
particular class. She ascertained that Cho had
trouble speaking in both English and Korean,
and she offered to connect him with the Dis-
ability Services Office.
After meeting with Cho, she e-mailed him to
reiterate her offers to go with him for counsel-
ing or for other services. He did not pursue
those offers. His written work was on time
and he was on time for class, but he missed
the last 2 weeks of class. Cho earned a B+ in
Norriss class that semester.
The following semester, spring 2007, Cho
began to buy guns and ammunition. His class
attendance began to fall off shortly before the
assaults. There were no outward signs of his
deteriorating mental state. In their last phone
call with him the night of April 15, 2007, Mr.
Cho and Mrs. Cho had no inkling that any-
thing was the matter. Cho had called per their
usual Sunday night arrangement. He
appeared his regular self. He asked how his
parents were, and other standard responses:
No I do not need any money. His parents
said, I love you.
MISSING THE RED FLAGS
he Care Team at Virginia Tech was estab-
lished as a means of identifying and work-
ing with students who have problems. That
resource, however, was ineffective in connect-
ing the dots or heeding the red flags that were
so apparent with Cho. They failed for various
reasons, both as a team and in some cases in
the individual offices that make up the core of
the team.
Key agencies that should be regular members
of such a team are instead second tier, non-
permanent members. One of these, the VTPD,
knew that Cho had been cautioned against
stalkingtwice, that he had threatened sui-
cide, that a magistrate had issued a tempo-
rary detention order, and that Cho had spent
a night at St. Albans as a result of such detention
order. The Care Team did not know the details of
all these occurrences.
Residence Life knew through their staff (two resi-
dent advisors and their supervisor) that there
were multiple reports and concerns expressed
over Chos behavior in the dorm, but this was not
brought before the Care Team. The academic
component of the university spoke up loudly about
a sullen, foreboding male student who refused to
talk, frightened classmate and faculty with maca-
bre writings, and refused faculty exhortations to
get counseling. However, after Judicial Affairs
and the Cook Counseling Center opined that Chos
writings were not actionable threats, the Care
Teams one review of Cho resulted in their being
satisfied that private tutoring would resolve the
problem. No one sought to revisit Chos progress
the following semester or inquire into whether he
had come to the attention of other stakeholders on
campus.
The Care Team was hampered by overly strict
interpretations of federal and state privacy laws
(acknowledged as being overly complex), a decen-
tralized corporate university structure, and the
absence of someone on the team who was experi-
enced in threat assessment and knew to investi-
gate the situation more broadly, checking for col-
lateral information that would help determine if
this individual truly posed a risk or not. (The in-
terpretation of FERPA and HIPAA rules is dis-
cussed in a later chapter.)
There are particular behaviors and indicators of
dangerous mental instability that threat assess-
ment professionals have documented among mur-
derers. A list of red flags, warning signs and indi-
cators has been compiled by a member of the
panel and is included as Appendix M.
KEY FINDINGS CHOS COLLEGE
YEARS TO APRIL 15, 2007 T
he lack of information sharing among aca-
demic, administrative, and public safety enti-
ties at Virginia Tech and the students who had
raised concerns about Cho contributed to the fail-
ure to see the big picture. In the English Depart-
T
T
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
53
ment alone, many professors encountered
similar difficulties with Chonon- participa-
tion in class, limited responses to efforts to
personally interact, dark writings, reflector
glasses, hat pulled low over face. Although to
any one professor these signs might not neces-
sarily raise red flags, the totality of the re-
ports would have and should have raised
alarms.
Chos aberrant behavior of pathological shy-
ness and isolation continued to manifest
throughout his college years. He shared very
little of his college life with his family, had no
friends, and engaged in no activities outside of
the home during breaks and summer vaca-
tions. While he was an adult, he was a mem-
ber of the household and receiving parental
support, but he did not hold a job to help earn
money for college. Unusual by U.S. standards,
a high, sometimes exclusive focus on academ-
ics is common among parents from eastern
cultures.
Chos roommates and suitemates noted fre-
quent signs of aberrant behavior. Three fe-
male residents reported problems with un-
wanted attention from Cho (instant messages,
text messages, Facebook postings, and erase
board messages). One of Chos suitemates
combined many of these instances of concern
into a report shared with the residence staff.
The residence advisors reported these matters
to the hall director and the residence life ad-
ministrator on call. These individuals in turn,
communicated by e-mail with the assistant
director of Judicial Affairs.
Notwithstanding the system failures and
errors in judgment that contributed to Chos
worsening depression, Cho himself was the
biggest impediment to stabilizing his mental
health. He denied having previously received
mental health services when he was evaluated
in the fall of 2005, so medical personnel be-
lieved that their interaction with him on that
occasion was the first time he had showed
signs of mental illness. While Chos emotional
and psychological disabilities
undoubtedly clouded his ability to evaluate his
own situation, he, ultimately, is the primary per-
son responsible for April 16, 2007; to imply other-
wise would be wrong.
RECOMMENDATIONS
IV-1 Universities should recognize their
responsibility to a young, vulnerable
population and promote the sharing of
information internally, and with parents,
when significant circumstances pertaining to
health and safety arise.
IV-2 Institutions of higher learning should
review and revise their current policies
related to
a) recognizing and assisting students in dis-
tress
b) the student code of conduct, including en-
forcement
c) judiciary proceedings for students, includ-
ing enforcement
d) university authority to appropriately in-
tervene when it is believed a distressed stu-
dent poses a danger to himself or others
IV-3 Universities must have a system that
links troubled students to appropriate medi-
cal and counseling services either on or off
campus, and to balance the individuals
rights with the rights of all others for safety.
IV-4 Incidents of aberrant, dangerous, or
threatening behavior must be documented
and reported immediately to a colleges
threat assessment group, and must be acted
upon in a prompt and effective manner to
protect the safety of the campus community.
IV-5 Culturally competent mental health ser-
vices were provided to Cho at his school and
in his community. Adequate resources must
be allocated for systems of care in schools
and communities that provide culturally
competent services for children and adoles-
cents to reduce mental-illness-related risk as
occurred within this community.
IV-6 Policies and procedures should be
implemented to require professors
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
54
encountering aberrant, dangerous, or
threatening behavior from a student to
report them to the dean. Guidelines should
be established to address when such reports
should be communicated by the dean to a
threat assessment group, and to the schools
counseling center.
IV-7 Reporting requirements for aberrant,
dangerous, or threatening behavior and
incidents for resident hall staff must be
clearly established and reviewed during
annual training.
IV-8 Repeated incidents of aberrant, dan-
gerous, or threatening behavior must be
reported by Judicial Affairs to the threat
assessment group. The group must formu-
late a plan to address the behavior that will
both protect other students and provide the
needed support for the troubled student.
IV-9 Repeated incidents of aberrant, dan-
gerous, or threatening behavior should be
reported to the counseling center and
reported to parents. The troubled student
should be required to participate in counseling
as a condition of continued residence in cam-
pus housing and enrollment in classes.
IV-10 The law enforcement agency at col-
leges should report all incidents of an is-
suance of temporary detention orders for
students (and staff) to Judicial Affairs,
the threat assessment team, the counsel-
ing center, and parents. All parties should be
educated about the public safety exceptions to the
privacy laws which permit such reporting.
IV-11 The college counseling center should
report all students who are in treatment pur-
suant to a court order to the threat assess-
ment team. A policy should be implemented to
address what information can be shared with fam-
ily and roommates pursuant to the public safety
exceptions to the privacy laws.
IV-12 The state should study what level of
community outpatient service capacity will
be required to meet the needs of the common-
wealth and the related costs in order to ade-
quately and appropriately respond to both
involuntary court-ordered and voluntary re-
ferrals for those services. Once this informa-
tion is available it is recommended that out-
patient treatments services be expanded
statewide.
The panels report deals with facts. Sometimes,
however, police investigation requires educated
guesses and speculationsuch as in instances
where a profile of an unknown killer is gener-
ated by FBI profilers, who are specially trained in
this area. Set forth in Appendix N is such a work,
written by panel member Dr. Roger Depue, who
is, among many other qualifications, a former FBI
profiler. While no member of the panel can defini-
tively ascertain what was in Chos mind, this pro-
file offers one theory.



The Commonwealth of Virginia Commission on
Mental Health Law Reform was appointed in
October 2006, by Virginia Chief Justice Leroy R.
Hassell, Sr. The 26-member commission,
chaired by Professor Richard J. Bonnie, Director
of the Institute of Law, Psychiatry and Public
Policy at the University of Virginia, is charged
to conduct a comprehensive examination of
Virginias mental health laws and services and
to study ways to use the law more effectively to
serve the needs of people with mental illness,
while respecting the interests of their families
and communities.
The commission has held four meetings with
another scheduled for November 2007 and is
working through five task forces with more than
200 participants. The Task Force on Civil Com-
mitment is addressing criteria for inpatient and
outpatient commitment, transportation, and the
emergency evaluation process, procedures for
Part B Virginia Mental Health Law Issues
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
55
hearings, training, and compensation for par-
ticipants in the process, and oversight.
The Task Force on Civil Commitment will sub-
mit its final report to the commission in Novem-
ber 2007. The commission intends to prepare a
preliminary report during the winter and to
submit a final report by the fall of 2008 for con-
sideration by the 2009 General Assembly.
The discussion that follows constitutes an
abridged effort, due to constraints of time and
manpower, to address some of the issues that
will be dealt with by the commission in a far
more comprehensive manner. Many of the
panels recommendations are framed in general
terms with the expectation that the commission
will formulate specific proposals.
Throughout the panels work, there was close
collaboration with Professor Bonnie and James
Stewart, the Inspector General for the Depart-
ment of Mental Health and Mental Retardation
and Substance Abuse Services. The inspector
general released a report in June 2007 detailing
his findings concerning Chos interaction with
mental health services in Virginia.
TIME CONSTRAINTS FOR
EVALUATION AND HEARING
Va. Code 37.2-808 establishes the procedures for
involuntary temporary detention of persons who
are mentally ill, present an imminent danger to
self or others, and are in need of hospitalization
but unwilling or unable to volunteer for treat-
ment. Subsection H provides that no person
shall remain in custody for longer than 4 hours
without a temporary detention order issued by a
magistrate. In Chos case, the New River Valley
CSB was able to provide a pre-screener in a
timely manner, and she was able to conduct the
screening and locate an available bed in order to
present the matter to the magistrate within the
required 4-hour period.
However, mental health service providers and
special justices interviewed for this report set
forth numerous arguments as to why this period
should be lengthened to either 6 hours or to
permit one renewal of the 4-hour period for good
cause. The concerns raised included that it is
often difficult to promptly secure qualified per-
sonnel to perform the prescreening evaluation
given staff resources and required travel time,
particularly in rural jurisdictions. It is often
even more difficult to locate the available bed
required for a temporary detention order (TDO)
to issue. Four hours do not allow sufficient time
to gather meaningful collateral information
from family, friends, or other health care pro-
viders nor to secure proper evaluations for
medical clearance. Some noted, however, that
an extension of the 4-hour period may require
police departments to spend more time with a
person in emergency custody in those locales
where hospital security are unable to assume
responsibility.
The American College of Emergency Physicians
(ACEP) has recommended that emergency
physicians trained in psychiatric evaluation be
given more authority in the involuntary hold
process. Since emergency departments are 24-
hour facilities, resources are already in place.
Because the CSB serves an independent
gatekeeper role under the Virginia TDO
process, emergency physicians and CSB staff
are generally expected to work collaboratively in
determining whether a TDO is needed for those
patients screened in emergency departments.
However, where CSB pre-screeners are not
immediately available, properly trained
emergency physicians can effectively screen
patients under an emergency custody order and
communicate with the magistrate to obtain the
TDO when needed. If such a gate keeping
responsibility were to be conferred on
emergency physicians, further questions would
have to be addressed regarding the respective
roles of the emergency physicians and the CSB
staff in exploring alternatives to hospitalization
and in participating in the commitment hearing.
Under current Virginia law, the duration of
temporary detention may not exceed 48 hours
prior to a hearing (or the next day that is not a
Saturday, Sunday, or legal holiday). The mental
health service providers in Chos case were able
to comply with the 48-hour requirement;
however, the information available to the
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
56
special justice was extremely limited. There was
no history regarding prior treatment; there were
no lab or toxicology reports, nor the report
regarding access to a firearm. At the hearing,
there were no witnesses present such as family,
roommate/suitemates, the CSB pre-screener,
the independent evaluator, or the treating
psychiatrist.
Mental health professionals interviewed
reported that 48 hours is one of the shortest
detention periods in the nation and recom-
mended that it be lengthened. Reasons cited for
expanding this period included the need to con-
tact family or friends and to explore the persons
prior history. Also cited was the need for a more
comprehensive independent evaluation and the
difficulty in securing a complete report of the
treating psychiatrist in time for the hearing. It
was suggested that a psychiatric workup as
well as a toxicology screen be available to the
independent examiner. A further concern was
that often psychiatric inpatient bed space is not
available within the 48 hours. As a financial
consideration, it was argued that a longer period
would allow patients an opportunity to stabilize
or recognize the need for voluntary treatment,
thereby reducing the number of commitment
hearings and the costs associated with special
justices and appointed counsel.
STANDARD FOR INVOLUNTARY
COMMITMENT
The judge or special justice ordering commit-
ment must find by clear and convincing evi-
dence that the person presents (1) an imminent
danger to himself or others or is substantially
unable to care for himself, and (2) less restric-
tive alternatives to involuntary inpatient treat-
ment have been investigated and are deemed
unsuitable. Cho was found to be an imminent
danger to himself by the pre-screener who also
found that he was unable to come up with a
safety plan to adequately ensure safety. He was
unwilling to contact his parents to pick him up.
However, Cho was found not to be an imminent
danger to self or others by both the independent
examiner and the treating psychiatrist at St.
Albans, and accordingly neither recommended
involuntary admission. At the commitment
hearing, the special justice did find Cho to be an
imminent danger to himself; however, he agreed
with the independent examiner and treating
psychiatrist that a less restrictive alternative to
involuntary admission, outpatient treatment,
was suitable. Perhaps Cho presented himself
differently at various stages of the commitment
process or perhaps the professionals had differ-
ing evaluations of someone who did not speak
much or perhaps they had differing interpreta-
tions of the standard set forth in the Virginia
Code.
Mental health professionals advised the panel
that the standard imminent danger to self or
others is not clearly understood and is subject
to differing interpretations. They recommend
that the criteria for commitment be revised to
achieve a more consistent application. Service
providers and special justices suggest that the
imminent danger criterion should be replaced
by language requiring a substantial likelihood
or significant risk that the person will cause
serious injury to himself or others in the near
future. A few disagreed on the basis that per-
sonal rights of liberty should be paramount, and
that changing the standard would lower the
threshold for admission. Proponents for modify-
ing the criteria respond that Virginias commit-
ment standard is one of the most restrictive of
all the states. They contend that the threshold
finding prevents intervention in cases of severe
illness accompanied by substantial impairment
of cognition, emotional stability, or self-control.
PSYCHIATRIC INFORMATION
Many of those interviewed expressed serious
concerns regarding the paucity of psychiatric
information available to the independent
evaluator and judge/special justice. As noted
above, the independent evaluator for Cho had
only the report from the CSB pre-screener and
no collateral information or medical records.
The independent evaluator plays a key role in
the commitment process in many jurisdictions.
In Chos case, notwithstanding the finding from
the independent evaluator that Cho did not pose
an imminent threat, the special justice,
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
57
nevertheless convened the hearing and actually
made a finding that differed from that of the
independent evaluator. He did, however, agree
with the independent evaluator that inpatient
treatment was not required. The panel was
advised that in many jurisdictions, absent a
finding by the independent evaluator that an
individual poses an imminent danger or is
substantially unable to care for himself, many
special justices will decline to hold a hearing.
It is unclear under existing law whether the in-
dependent evaluator is intended to serve as a
gate keeper. If the opinion of the independent
evaluator is to be given great weight, then it is
critical that sufficient psychiatric information be
available upon which an informed judgment
may be made. Background information includ-
ing records from the current hospitalization
must be assembled for review. The Cho case
calls attention to the need to assure that the
independent evaluator has both sufficient time
and information to conduct an adequate evalua-
tion.
At Chos hearing, the only documents available
to the special justice were the Uniform Pre-
Admission Screening Form, a partially com-
pleted Proceedings for Certification form
recording the findings of the independent
evaluator and a physicians examination form
containing the findings of the treating psychia-
trist. No prior patient history was presented; no
toxicology, lab results, or physical evaluation
from the treating psychiatrist were available.
The admitting form indicating that Cho had
access to a firearm was not presented.
Panel members have been advised by mental
health providers and special justices from other
locales in Virginia that it is not unusual for the
evidence presented at commitment hearings to
be minimal. Due to the time constraints and
limitations of resource personnel, the informa-
tion available to the judge/special justice is often
very limited. Witnesses cannot be located
quickly and hospital records have often not been
transcribed. Additionally, conflicting interpreta-
tions of the constraints of the Health Insurance
Portability and Accountability Act (HIPAA) and
Virginia Code 32.1-127.1:03 Health Records Pri-
vacy (VaHRP) often make it difficult to acquire
background medical/psychiatric information on
a patient previously treated elsewhere. Legal
experts from a research advisory group for the
Commission on Mental Health Law Reform par-
ticipated in the development of a questionnaire
for judges and special justices to complete fol-
lowing civil commitment hearings in the month
of May 2007. More than 1400 questionnaires
were returned. They reflected that approxi-
mately 60 percent of the May hearings lasted no
more than 15 minutes and only 4 percent
required more than 30 minutes.
Cho was the only person to testify at his com-
mitment hearing, and he was not very commu-
nicative. The pre-screener was not present nor
was any representative from the CSB. The
independent evaluator was not present. The
officer who detained Cho was not present. Chos
roommate, suitemates, and Chos family were
all absent. This apparently is not an unusual
scenario for commitment hearings in Virginia.
Often the pre-screener is off duty by the time of
the hearing. CSBs with limited staff frequently
do not send a substitute. (The commissions sur-
vey reflected that the CSB representatives
attended only half of the hearings held in May,
2007). Independent evaluators, paid $75 per
commitment evaluation, often feel compelled to
return to their private practice rather than
waiting for hearings that may be held hours
after the evaluation is complete. (The responses
to the questionnaires indicated that the inde-
pendent evaluators were present at approxi-
mately two-thirds of Mays hearings.) Due to
time constraints and concerns regarding HIPAA
and VaHRP restrictions, friends and family are
often not notified.
HIPAA and VaHRP generally require that no
health care entity disclose an individuals health
records or information. However, permitted
exceptions are information necessary for the
care of a patient and information concerning a
patient who may present a serious threat to
public health or safety. Therefore, a treating
physician at the facility where a patient is
detained should be granted access to all prior
psychiatric history. These exceptions, however
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
58
do not clearly permit these records be shared
with the judge or special justice at the commit-
ment hearing. Although a person may consent
to the release of information to any person or
entity, detained individuals are often unable or
disinclined to do so.
Because interpretation of HIPAA and FERPA
were key in stopping adequate exchange of in-
formation concerning Cho, the panel requested
that its legal council research the interpretation
and exceptions under these laws, which is pre-
sented in the next chapter.
INVOLUNTARY OUTPATIENT ORDERS
In conducting the investigation, the panel
encountered many questions concerning invol-
untary outpatient orders. What specificity
should be required of outpatient orders? To
whom should notice of outpatient orders be
given? How should compliance with outpatient
orders be monitored? What procedures should
be available to address noncompliance and what
resources are needed?
The special justice ordered that Cho receive
outpatient treatment; however, the order pro-
vided no information regarding the nature of the
treatment other than to state to follow all rec-
ommended treatments. The order did not spec-
ify who was to provide the outpatient treatment
or who was to monitor the treatment.
There was considerable support among those
interviewed by panel members for greater guid-
ance in the Virginia Code regarding outpatient
treatment orders. Some felt that the order
should track recommendations from the treating
physician as to the frequency and duration of
treatment and whether medication was
required. Others observed that often physicians
evaluations and orders were not available and
the special justice/substitute judge did not have
the expertise to order specific treatment. How-
ever, all agreed that more specificity in out-
patient treatment orders is essential.
New River Valley CSB did not have a represen-
tative at Chos hearing due to financial con-
straints. Va. Code 37.2-817(C) currently
requires the CSB to recommend a specific course
for involuntary outpatient treatment and to
monitor compliance. However, the Code does not
specify how or by whom the CSB will be notified
that outpatient treatment has been ordered if a
representative is not present at the hearing.
There exists a disagreement as to whether the
CSB was advised of the entry of the outpatient
order in Chos case. The clinical support repre-
sentative for St. Albans advised that he always
calls the CSB following commitment hearings to
report the results. The CSB reports that they
have no record of having been notified. If the
CSB is represented at the hearing, there can be
no reason for confusion. However, if Virginia
Code is not amended to require the presence in
person or telephonically, it must be amended to
designate who has responsibility for certifying a
copy of the outpatient order to the CSB. There
should also be clear guidance provided in the
Virginia Code as to who has responsibility for
notification if a private mental health practitio-
ner is to provide the mandated outpatient
treatment.
No notice of the hearing or the order issued by
the special justice was given to Chos family, his
roommate/suitemates, the VTPD, or the Vir-
ginia Tech administration. The Code of Virginia
authorizes no such notice. The recordings of the
hearing must be kept confidential pursuant to
Va. Code 37.2-818(A). The records, reports and
court documents pertaining to the hearing are
kept confidential if so requested by the subject
of the hearing under 37.2-818(B) and are not
subject to the Virginia Freedom of Information
Act. HIPAA and VaHRP restrictions may fur-
ther limit dissemination of certain information
as no person to whom health records are dis-
closed may redisclose beyond the purpose for
which disclosure was made. Concerns were
raised by many interviewees and speakers at
panel hearings that family members, those
residing with the subject of a commitment hear-
ing, the police department and school officials
should all be notified of the hearing and its out-
come in the interest of public safety.
In Chos case, there are conflicting reports re-
garding the issue of notice to the treatment pro-
vider, Cook Counseling Center. An appointment
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
59
had been scheduled by Cho with the assistance
of the clinical support representative for St.
Albans. The representative reports that he
faxed a copy of the discharge summary to Cook.
Cook, however, contends that they did not
receive any written documentation until Janu-
ary, and even then it was the physical examina-
tion which indicated that Cho would be treated
by the St. Albans psychiatrist. Following Chos
in-person triage appointment on December 14,
the Cook Counseling Center left it to Chos dis-
cretion whether to return for follow up treat-
ment. When he did not, it was not reported to
the special justice, St. Albans, or the CSB. The
Virginia Code imposes no legal obligation for
Cook Counseling Center to do so, and Cook
counselors question whether they have the right
to do so given the restrictions of HIPAA and
VaHRP.
Furthermore, there exists the question of
whether Cho was noncompliant given the gen-
eral language of the involuntary treatment
order; and if Cho were considered noncompliant,
how was that to be addressed. There is no con-
tempt provision in the Virginia Code for those
noncompliant with involuntary outpatient
orders. There is no guidance as to the nature of
the hearing to be held for noncompliance; nor is
there a basis for compensating the special
justice/substitute judge or attorney for followup
proceedings. Many questions are raised. If a
form is created to report noncompliance, can a
treatment provider file the report without vio-
lating HIPAA and VaHRP? If the noncompli-
ance report is filed, how does the special justice
secure the presence of the individual for a fol-
lowup hearing? If the noncompliant individual
does not pose an imminent danger to himself or
others at the time of the followup hearing, an
emergency custody order cannot be issued; nor
can the special justice order involuntary in-
patient treatment. Should there be a Code pro-
vision allowing for a short period of inpatient
treatment for those not compliant with the out-
patient order yet not an imminent danger at
the time returned for noncompliance? Will
commitment for noncompliance pose yet another
burden on the already overcrowded inpatient
facilities?
On June 22, 2007, the Commission on Mental
Health Law Reform released the final report of
its study of the current commitment process.
This study, undertaken for the commission by
Dr. Elizabeth McGarvey of the University of
Virginia School of Medicine, involved intensive
interviews with 64 professional participants in
the process, 60 family members of persons with
serious mental illness, and 86 people who have
had the experience of being committed. Accord-
ing to Dr. McGarveys report, professional par-
ticipants and family stakeholders are uniformly
frustrated by almost every aspect of the civil
commitment process in Virginia. Among the
most common complaints were a shortage of
beds in willing detention facilities, insufficient
time for adequate evaluation, the high cost and
inefficiency of transporting people for evalua-
tion, inadequate compensation for professional
participants in the process, inadequate reim-
bursement for hospitals, inconsistent interpre-
tation of the statute by different judges, and
lack of central direction and oversight.
CERTIFICATION OF ORDERS TO THE
CENTRAL CRIMINAL RECORDS
EXCHANGE
Va. Code 37.2-819 requires the clerk to certify,
on a form provided, any order for involuntary
admission to the Central Criminal Records
Exchange. The section does not specify who
bears responsibility for completion of the form.
The failure of Va. Code 37.2-819 to specify
responsibility for preparation of the order fur-
nished by the Central Criminal Records
Exchange was noted to be a problem. It is
reported that in some jurisdictions, if the clerk
is not furnished the completed form, no form is
forwarded to the exchange. There is lack of con-
sistency throughout the Commonwealth regard-
ing who prepares the forms. In some jurisdic-
tions, the forms are completed by the special
justice/substitute judge, in others by the clerk of
court, and reportedly in others, the forms are
often not completed at all.
Of further concern was the issue of under what
circumstances the forms are to be completed.
Mental health and legal professionals
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
60
interviewed by panel members felt that there
was no reasonable distinction to be drawn be-
tween persons ordered for involuntary inpatient
treatment and those ordered for involuntary
out-patient treatment when a finding has been
made that the individual poses an imminent
danger to self or others. If firearms restrictions
apply, they should be based upon the fact that
an individual poses a danger, not on the basis of
the type of treatment ordered; therefore, both
involuntary inpatient and involuntary out-
patient treatment orders should be certified.
While the governor has addressed this matter
by executive order, it was felt that legislation
should be enacted embodying the certification
requirement. Mental health and legal experts
also raised the question of whether persons
electing voluntary admission upon being ad-
vised of their right to do so during the commit-
ment hearing should also be reported. (The
commissions survey indicated that 30 percent of
the commitment hearings in May resulted in
voluntary admission.)
It was also noted with concern by the mental
health and legal experts interviewed that the
reporting requirement does not apply to orders
for juveniles found to pose an imminent danger,
regardless of whether inpatient or outpatient
treatment was ordered. They further expressed
concern regarding the absence of any provision
in the Virginia Code requiring the clerk to cer-
tify orders pertaining to persons found not
guilty by reason of insanity.
KEY FINDINGS
Statutory time constraints for temporary deten-
tion and involuntary commitment hearings sig-
nificantly impede the collection of vital psychi-
atric information required for risk assessment.
The Virginia standard for involuntary commit-
ment is one of the most restrictive in the nation
and is not uniformly applied.
The fact that a CSB representative did not
attend the commitment hearing and the failure
to certify a copy of the outpatient commitment
order to the CSB resulted in an absence of over-
sight for Chos outpatient treatment.
The lack of a requirement in the Virginia Code
to certify outpatient commitment orders to the
CCRE resulted in Chos name not being entered
in the database, which could have prevented his
purchase of firearms.
There was a lack of doctor-to-clinician contact
between St. Albans Hospital and the Cook
Counseling Center.
In the wake of the Virginia Tech tragedy, much
of the discussion regarding mental health ser-
vices has focused on the commitment process.
However, the mental health system has major
gaps in its entirety starting from the lack of
short-term crisis stabilization units to the out-
patient services and the highly important case
management function, which strings together
the entire care for an individual to ensure suc-
cess. These gaps prevent individuals from get-
ting the psychiatric help when they are getting
ill, during the need for acute stabilization, and
when they need therapy and medication man-
agement during recovery.
RECOMMENDATIONS
IV-13 Va. Code 37.2-808 (H) and (I) and
37.2-814 (A) should be amended to extend
the time periods for temporary detention to
permit more thorough mental health
evaluations.
IV-14 Va. Code 37.2-809 should be amended
to authorize magistrates to issue temporary
detention orders based upon evaluations
conducted by emergency physicians trained
to perform emergency psychiatric evalua-
tions.
IV-15 The criteria for involuntary
commitment in Va. Code 37.2-817(B) should
be modified in order to promote more
consistent application of the standard and
to
allow involuntary treatment in a broader
range of cases involving severe mental
illness.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
61
IV-16 The number and capacity of secure
crisis stabilization units should be
expanded where needed in Virginia to
ensure that individuals who are subject to
a temporary detention order do not need to
wait for an available bed. An increase in
capacity also will address the use of inpatient
beds for moderately to severely ill patients that
need longer periods of stabilization.
IV-17 The role and responsibilities of the
independent evaluator in the commitment
process should be clarified and steps taken
to assure that the necessary reports and
collateral information are assembled be-
fore the independent evaluator conducts
the evaluation.
IV-18 The following documents should be
presented at the commitment hearing:
The complete evaluation of the treating
physician, including collateral infor-
mation.
Reports of any lab and toxicology tests
conducted.
Reports of prior psychiatric history.
All admission forms and nurses notes.
IV-19 The Virginia Code should be
amended to require the presence of the pre-
screener or other CSB representative at all
commitment hearings and to provide
adequate resources to facilitate CSB
compliance.
IV-20 The independent evaluator, if not
present in person, and treating physician
should be available where possible if
needed for questioning during the hearing.
IV-21 The Virginia Health Records Privacy
statute should be amended to provide a safe
harbor provision which would protect
health entities and providers from liability
or loss of funding when they disclose infor-
mation in connection with evaluations and
commitment hearings conducted under
Virginia Code 37.2-814 et seq.
IV-22 Virginia Health Records Privacy and
Va. Code 37.2-814 et seq. should be amended
to ensure that all entities involved with
treatment have full authority to share
records with each other and all persons in-
volved in the involuntary commitment
process while providing the legal safe-
guards needed to prevent unwarranted
breaches of confidentiality.
IV-23 Virginia Code 37.2-817(C) should be
amended to clarify
the need for specificity in involuntary
outpatient orders.
the appropriate recipients of certified
copies of orders.
the party responsible for certifying cop-
ies of orders.
the party responsible for reporting non-
compliance with outpatient orders and
to whom noncompliance is reported.
the mechanism for returning the non-
compliant person to court.
the sanction(s) to be imposed on the no-
compliant person who does not pose an
imminent danger to himself or others.
the respective responsibilities of the
detaining facility, the CSB, and the
outpatient treatment provider in assur-
ing effective implementation of involun-
tary outpatient treatment orders.
IV-24 The Virginia Health Records Privacy
statute should be clarified to expressly
authorize treatment providers to report
noncompliance with involuntary outpatient
orders.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62
IV-25 Virginia Code 37.2-819 should be
amended to clarify that the clerk shall
immediately upon completion of a commit-
ment hearing complete and certify to the
Central Criminal Records Exchange, a copy
of any order for involuntary admission or
involuntary outpatient treatment.
IV-26 A comprehensive review of the
Virginia Code should be undertaken to
determine whether there exist additional
situations where court orders containing
mental health findings should be certified
to the Central Criminal Records Exchange.

CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - A
ADDITIONS AND CORRECTIONS
Ruling on Chos Poem: p. 43, Clarification To be clear, it was the content of the poem
written by Cho to which Director of Judicial Affairs Frances Keene was referring in the second
paragraph, second column, which might have been confusing because the immediately preced-
ing issue discussed in the paragraph is Chos secret photos in the classroom.
Name and Title: p. 44, Correction Rohsaan Settle should have been identified as a mem-
ber of the Residence Life staff and not the Assistant Director of Judicial Affairs. The reference
to Settle as she also is incorrect.
E-mail to Rohsaan Settle: p. 44, Addition The email Settle received on December 6 con-
cerning Chos behavior was sent by an RA, Lisa Virga. She advised Settle of Chos odd behav-
ior and described Chos stalking of a student, Christina Lillizu, who lived in Cochrane resi-
dence hall on the other side of the third floor where Cho lived. Cho had a class with Lillizu. He
harassed her online, talked to her on IM, and went to her room twice, once in disguise. Lillizu
reportedly did not confront Cho because she was afraid to but did contact VTPD after Cho ap-
peared at her door in disguise. (The exact date and time of the VTPD contact are not known
because there is no incident report at VTPD on that contact.) Ms. Virga also explained to Settle
that Cho had two knives in the dorm room, though she did not specify the size of the knives.
Mr. Settle responded to the RA that they should chat about the knives. There are no records
indicating that Mr. Settle followed up with VTPD to report the possession of knives which, if
of a certain size, was a violation of the Code of Conduct - and the pattern of Chos aberrant be-
havior. Mr. Settle has said he is not sure if he responded to the information in Virgas email
but he thought VTPD was handling it.
Nature of Complaint: p. 45, Addition The text says on Sunday, November 27, the po-
lice, following a complaint from a female student who lived on the fourth floor of West Ambler
Johnston, came to Chos room to talk to him. To elaborate, it was about 11:30 p.m. when a
VTPD officer responded to 4021 West Ambler Johnston due to a harassment complaint from
student Jennifer Nelson. She reported that she had received multiple IMs from someone who
gave a false address and false email address. He also had called her. Nelson had no idea who
he was, though he said they went to the same high school; she had identified him through
Facebook. He had just come to her room, calling himself The Question Mark Kid. Nelson and
her roommate told him to leave and said they were calling police.
The officer investigated the moniker question mark on Facebook and confirmed Chos identi-
fication and address after speaking with one of the individuals listed as Chos friend. The offi-
cer immediately went to Chos dorm room, read him his Miranda rights, and questioned him.
The officer told Cho not to have any contact with Nelson by any means. Cho also was told there
could be a judicial referral filed, but no criminal charges were being placed at that time.
The officer then returned to West Ambler Johnston to speak with Nelson. Nelson read Chos
statement, said she did not want to press criminal charges but would be comfortable testifying
if there were a judicial hearing. The officer advised Nelson he would file a judicial referral,
which he did. According to Virginia Tech policy, either a law enforcement officer or a victim can
make a judicial referral. However, when Judicial Affairs followed up with Nelson they told her
that in addition to the VTPD referral, she, too, would have to make a referral for them to pur-
sue the matter. She declined.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - B
Chos CCC File: p. 46, Corrections and Clarification There are several corrections to the
text in the second paragraph of the left column. First the written documentation of Dr. Betzels
December 12 triage of Cho is no longer missing as it is part of the file found in Dr. Millers
home, as discussed previously. Second, the consultation between Dr. Betzel and Dr. Roy is mis-
placed in the chapter and should appear on page 43 as it relates to the activities surrounding
Chos removal from Dr. Giovannis class. Moreover, the last sentence of that paragraph should
be deleted and replaced with this text:
Dr. Roys consultation with Dr. Betzel occurred around October 18, 2005 during the
course of handling and following up on Dr. Giovannis alarm about Chos writings and
behavior in class. This consultation predated Chos triage appointments at CCC. There
should have been a Triage Report on this consultation somewhere in the CCC records,
but it would not typically have been part of a file on Cho unless it was connected to him
after his visit to CCC and his subsequent case file. There were no formal procedures for
what to do with these forms after they were reviewed by the CCC Director and returned
to the front desk.
According to the Virginia Inspector Generals report #179-09, Investigation-Records, Virginia
Tech Cook Counseling Center, p. 9, issued November 9, 2009, the practice at CCC in the fall of
2005 was as follows:
CCC counselors periodically had contact with faculty, university staff and parents who
sought consultation regarding students about whom they were concerned. This occurred
both for students who were being served by the Center and for students who had had no
contact with the Center. It was expected that each consultation was to be documented
on a separate Triage Form.
The Triage Forms were then to be placed in Dr. Millers inbox for review and later filing in the
front office where all Triage Forms on students whose cases have not yet been opened are
filed. To the extent that Triage Forms were completed for the consultations between faculty
and the CCC and between administrators and the CCC concerning Cho they would not have
been saved in a file with Chos name because he was not an established patient there at that
time. (Most of these communications were e-mails, not Triage Forms). Moreover, when a stu-
dent is not identified during a consultation (as was the case with at least one about Cho) the
Triage Form would likely not be linked to the student in question if he or she were to seek CCC
services later and have a file started at that time. It was not a requirement to name the indi-
vidual in question during a consultation.
Female Student Complaints About Cho: p. 46, Addition More details are available
about the call to VTPD on December 12, 2005. The complaint was from Margaret Bowman, 306
East Campbell residence hall, and regarded harassment by Cho. Bowman was upset over a se-
ries of unwanted communications over several days. Cho had sent her an IM on December 9.
Then, on December 11 in the evening, she discovered an excerpt from Shakespeare written on
the whiteboard outside her door. Returning from an exam the following morning, she found
that a continuation of the quotation from Shakespeare had been added. She believed Cho was
responsible because mutual friends told her that when they mentioned the situation to Cho he
commented that Shakespeare wrote it.
One of the responding officers went to Chos room and left a message with Chos roommate for
Cho to contact the officers; they also sent an email to Cho requesting the same.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - C
Discharge Summary to CCC: pp. 4849, Correction The last sentence of page 48 states
that Cook Counseling Center has no record of having received any hospital records until
January 2006, which is what had been reported to the Review Panel. It is now known that on
December 14, 2005 at 2:25 p.m., 35 minutes before Cho was seen at CCC, the CCC received a
fax from Diane Turner at Carilion Health System in Radford. The fax included a discharge
summary by Dr. Migliani which was transcribed on 12/14/05 at 11:57. The fax also included the
New River Valley Community Services Uniform Pre-admission Screening Form of 12/13/05
completed by Kathy Godbey. Full hospital records were mailed, but not received (or marked as
received) until 1/06.
Cho Writings and Professor Hicoks Class: p. 50, Corrections and Clarification The
Review Panels concern over not receiving from Professor Hicok a copy of Chos writing and of
that writing not being mentioned by Professor Hicok was largely unwarranted. Professor Hicok
had turned over some of Chos writings in his class to an FBI agent acting on behalf of the Vir-
ginia State Police just two days after the April 16 shootings. Hicok thought the VSP would
share the documents with the Review Panel, but they did not, apparently because they consid-
ered Chos writings part of their investigation file. Professor Hicok told the Review Panel that
Chos responses to writings by other students (not Chos own writing as stated in the Report)
were surprisingly cogent, but he was not a good creative writer. Cho was open to suggestions
and made some edits in response to the suggestions. Professor Hicok noted that Chos writing
was not unique in terms of subject matter, and though remarkable for violence, he added,
I have seen worse.
The writing of particular significance referred to in the Report was a play which described an
anguished students internal dialogue as he contemplates shooting students in a classroom. It
presaged Chos attack. For that reason, it was considered an especially important red flag. Cho
actually wrote that dark play, (an excerpt of which is reproduced on page 50) for a playwriting
workshop taught by Professor Ed Falco in the Fall of 2006, not for Professor Hicoks Fiction
Workshop class in Spring of 2006.
Lack of Further Police Contact Virginia Tech police noted that Cho had no further con-
tact with law enforcement after they took him for evaluation on Dec 13-14 2005 until he re-
ceived a speeding ticket on March 31, 2007, and they were not informed about his additional
problems.
More Lack of Attention to Red Flags: p. 53, Addition The finding that there was lack of
adequate attention by Virginia Tech to the red flags raised by Chos actions is reinforced by
further examination of communications among faculty and Virginia Tech staff. The Review
Panel faulted Virginia Tech for not connecting the dots. Since then, more unconnected dots
have come to light. Members of the Virginia Tech administration and campus police failed to
adequately heed warnings and take the initiative to investigate more fully a long list of fright-
ening writings and aberrant behaviors leading up to the shootings, especially those reported by
the resident advisors and English Department faculty. Examples are given in the various ad-
denda here, such as the discussion of the email to Settle above.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - D
OTHER COMMENTS
1. File on Cho at the CCC and the Relative Importance of Counseling for Cho: Some
of the comments that related to the CCCs file on Cho, placed a heavy emphasis on the im-
portance of that file and what impact counseling at CCC would have had on Cho. One indi-
vidual stated that those records were the linchpin that could have connected the dots. An-
other comment was that the Review Panel saw only some of Chos records, but not crucial
records.
Response: The papers in the file on Cho provided very little information that the Review
Panel did not already have. The Review Panel sought and received a huge amount of crucial
records, both academic and medical, from Chos middle school, high school, and Virginia
Tech years. The Review Panel also interviewed Chos high school counselor, doctors and
therapists in Northern Virginia, plus professors and health/mental health practitioners at
the CCC and at the CSB. The records from practitioners who treated Cho before he at-
tended Virginia Tech are far more informative and relevant than the intake forms in Chos
file from CCC. We also had his court records and met with Special Justice Paul M. Barnett
who conducted Chos commitment hearing. Additional factors to consider with regard to
Cho and counseling include the following:
Cho would not talk much. He was a poor candidate for traditional talk therapy because
he would not communicate, did not want to be in therapy, and was not legally required
to go for counseling. For therapy to have any effect and value to a patient the person
must truly want to participate in the sessions and work with the therapist. Cho con-
tacted CCC because he was getting into trouble with Virginia Tech police and then be-
cause it was required prior to his discharge from St. Albans. Since he lied about previ-
ous mental health problems, (including his ideas of suicide and homicide, prior years in
art therapy, and medication for depression), to all medical personnel, evaluators, and
court officials who dealt with him, he likely would have continued denying problems,
much like he denied being serious about his suicide threat.
Chos parents initiated therapy for Cho the summer before he started 7
th
grade because
they were concerned about his social isolation and unwillingness to discuss his thoughts
or feelings. The only therapy that could be used with Cho was art therapy, typically
used for very young children, because it did not require him to talk. His art therapist
told the Review Panel that through clay, drawings, and other media, she was able to di-
agnose his extreme loneliness and isolation. Some limited progress was made in con-
necting with him and getting him to make eye contact, though he remained unwilling to
respond verbally in a significant way.
There is an extremely relevant note in the psychological evaluation of Cho contained in
Chos high school files. The psychologist wrote: The quality of any diagnosis made or
care delivered will depend, to a large extent, on the quality of information exchanged in
both (emphasis added) directions. Psychological therapy in the form of counseling is
likely to be difficult and of limited effectiveness given Seung-Huis extreme reticence
and apparent anxiety. There are reports that Seung-Hui resents his participation in
therapy and attends only grudgingly.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - E
2. Availability of Home Town Doctor: One commenter asked, Why did the panel not
check into why Virginia Tech records indicate that there was a home town doctor or coun-
selor that Cho could see when he was home? What written document led the panel to make
their decision that Cho had a home town doctor or counselor?
Response: During Chos interactions with medical personnel on December 13-14, he had
nodded a yes to having doctors available at home, and that was noted on the record. Addi-
tionally, the Review Panel interviewed various health and mental health providers that had
treated Cho in Northern Virginia.
3. Dr. Roys Warning to Cho Regarding Referral to Judicial Affairs: A commenter
claimed that Dr. Roy and others failed to address or discuss that Cho was guilty of violating
the Code of Student Conduct and that Dr. Roy did not tell Cho that he had violated the CSC
and that similar behavior in the future would be referred to Judicial Affairs.
Response: Chapter IV, page 43, discusses the Code of Student Conduct, that Dr. Roy had
asked Dean Brown about it, and that he had responded that Chos cell phone picture-taking
would clearly fall under disorderly conduct, if adjudicated. Brown also spoke with Fran-
ces Keene who agreed with Dr. Roys plan to meet with Cho and propose individual work
with her and Professor Fred DAguiar. Keene communicated to Roy and Brown she was
available if Cho had questions. Moreover, detailed notes of the meeting with Cho, Dr. Roy,
and Cheryl Ruggiero (serving as assistant chair in the English Department at the time)
document the following exchange:
L: [Lucinda Roy] asks about Chos taking photos of the students in the class
Cho: says it is just a hobby, that he takes pictures of trees, sky
L: explains that taking unauthorized photographs, without permission from the subjects,
and especially publishing them on a website, is something the University is taking
very seriously, and that is could be something that could get a student into trou-
ble..asks if Seung understands
Cho: Yeah
4. Dr. Roy and Attempt to Get Cho to Seek Counseling: A commenter noted that the Re-
port states that Dr. Roy tells others she will try to get Cho to go to counseling, but she does
not mention it in her last email to Cho, or future communication.
Response: Dr. Roy urged Cho to get counseling multiple times and personally called CCC
to see if Cho could be required to get counseling. The counselor informed Dr. Roy of CCCs
then-existing rules that CCC only saw students who voluntarily sought counseling. Dr. Roy
pleaded with the counselor to come to Shanks Hall to meet Cho, and the counselor declined
due to then-existing CCC policy to only counsel students at the CCC. Dr. Roy writes in No
Right to Remain Silent (Chapter Two) about how often she brought up the subject of coun-
seling and Chos response was always noncommittal. She even offered to go with him to
CCC, and she recommended a particular counselor by name. Page 46 of the Report dis-
cusses Dr. Betzels recollection of Dr. Roy contacting her regarding a student Dr. Betzel be-
lieves was Cho, his writing, and Dr. Roys plans to meet with Cho individually.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - F
5. Notification to VTPD Regarding Chos Writings: There was an objection that the Re-
port did not discuss that Dr. Roy and Mary Ann Lewis failed to notify VTPD of the content
of Chos writings, and that Chos writings were not forwarded to a counselor.
Response: The Report discusses that Chos poem written in Dr. Giovannis class was sent
to the CCC for review and the CCC responded that Chos wirings, while disturbing, did not
seem threatening since he did not specify a target. He had not committed a crime therefore
contacting police and naming Cho would not have been appropriate. VTPD were informed
that security might be needed due to a concern in Dr. Giovannis classroom; however, since
Cho did not return to that class, the security was cancelled.
6. Criminal Charges Against Cho: The comment was that the report fails to reveal if crimi-
nal charges were filed by Margaret Bowman regarding Chos message on her white board
and Facebook/emails.
Response: Page 46 of the Report states: She [Bowman] did not file criminal charges.
7. Discrepancies Between the Inspector Generals Report, Investigation of April 16,
2007 Critical Incident at Virginia Tech and the Panel Report: A commenter charged
that information was intentionally omitted and misleading.
Response: There were two minor discrepancies between the two reports, both of which cov-
ered an enormous amount of detailed information. The two discrepancies are:
IGs report notes that Cho harassed Margaret Bowman on 3 occasions. The Review
Panel Report documents one. The Review Panel did not have the VTPD incident reports
which now are available, and which show the three dates. This addendum reflects the
additional incidents.
IGs report notes that the father of Chos suitemate called VTPD at 3:42 concerning
Chos suicide threat. Commenter says the Review Panel Report is incorrect and that
Chos suitemate [Andy Koch] did not call VTPD. However, a VTPD Incident/ Investiga-
tion Report dated 12/13/05 states: On 12-13-05 at approximately 1909 hours, I, Officer
Lucas received a phone call from [suitemate]Andy Koch Andy advised that Mr. Seung
Hui Cho had sent him an instant message earlier today saying that he was thinking
about killing himself. Andy Kochs father also may have contacted police independ-
ently.
8. Interviews of RAs: Commenter states the Review Panel only interviewed one RA, Melissa
Troutman and that other RAs should have been interviewed.
Response: Appendix B, page 9, of the original Report indicates the Review Panel inter-
viewed three RAs: Troutman, Chandler Douglas (the RA during Chos senior year) and Aus-
tin Moron.
9. Events of December 12, 2005 on: Commenter states that the Report lacks an accurate
account of what really happened from December 12
th
on, but that the IGs report covers
more details, so the Review Panel either was not given pertinent information or the Review
Panel wrote the Report so as to omit the accurate accounts.
Response: The Report devotes three pages to describe the events of December 12-13. Part
B of Chapter IV) describes in great detail the legal and mental health process involving Cho
and the implications for future improvements. Part B alone contains 12 recommendations.
CHAPTER IV. CHOS MENTAL HEALTH HISTORY
62 - G
10. Chos emergency custody and transport to St. Albans: Commenter states: the Report
says officers transported Cho to St. Albans for admission at 11:00. Stewarts (the IG) report
says he was admitted at 11:15. It took VTPD 4 hours to take Cho into emergency custody
after the magistrate issued the TDO.
Response: VTPD immediately took Cho to police headquarters for evaluation by a
mental health prescreener who arrived shortly after being called. The prescreener took time
interviewing Cho, the police, and Chos roommates by phone, and found a psychiatric bed at
St. Albans then contacted the magistrate to request a TDO. The TDO was issued at 10:12
p.m. Cho was in custody at the Virginia Tech police station during this time. Police then left
with Cho at 11:00 p.m. to travel to St. Albans. The hospital admitted Cho at 11:15.
11. Screening form and box for access to firearms and finding of error: Commenter
states that the screening form released on 8/19/09 does not include a form with a box for
firearm access and asks why it was not released and on what the Review Panel based its
finding that the marked box was an error. Claims it is very likely that Cho had possession
of a gun at that time.
Response: Several intake and screening forms were used for Chos evaluation and treat-
ment process and release from Carillion St. Albans. The form completed by the CSB evalua-
tor Kathy Godbey during her preliminary screening of Cho at VTPD includes the question
on access to a firearm. The Review Panel was provided with a copy of that, and all other in-
take and screening forms. The Review Panel members interviewed Ms. Godbey who indi-
cated that she might have inadvertently checked the wrong box, because if the Yes box is
checked, then the evaluator must describe the access and the firearm, and she had not writ-
ten anything on that line. There are no indications that Cho had possession of any gun until
his purchase in early 2007.
12. Information sent to CCC and staff emails: Commenter notes there was an email be-
tween Emily Conway, a member of the CCC support staff and Dr. Miller at 4:24 on Decem-
ber 14, 2005, less than 45 minutes after Cho was seen and maintains the email was delib-
erately omitted.
Response: The Report includes discussion of this email. There were two relevant communi-
cations at CCC on December 14, 2005. The first was the fax with the St. Albans discharge
summary and CSB evaluators report received shortly before Cho was seen at 3:00. The sec-
ond was an email sent to Dr. Miller from Sandra Ward, the Director of Residence Life,
which described the events of the previous night and Chos transfer to St. Albans. Dr. Miller
immediately forwarded this to CCC staff as an alert in case Cho came to CCC.

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63
Chapter V.
INFORMATION PRIVACY LAWS
hile Cho was a student at Virginia Tech, his
professors, fellow students, campus police,
the Office of Judicial Affairs, the Care Team, and
the Cook Counseling Center all had dealings with
him that raised questions about his mental stabil-
ity. There is no evidence that Cho's parents were
ever told of these contacts, and they say they were
unaware of his problems at school. Most signifi-
cantly, there is no evidence that Cho's parents, his
suitemates, and their parents were ever informed
that he had been temporarily detained, put
through a commitment hearing for involuntary
admission, and found to be a danger to himself.
Efforts to share this information was impeded by
laws about privacy of information, according to
several university officials and the campus police.
Indeed, the universitys attorney, during one of
the panels open hearings and in private meetings,
told the panel that the university could not share
this information due to privacy laws.
The panel's review of information privacy laws
governing mental health, law enforcement, and
educational records and information revealed
widespread lack of understanding, conflicting
practice, and laws that were poorly designed to
accomplish their goals. Information privacy laws
are intended to strike a balance between protect-
ing privacy and allowing information sharing that
is necessary or desirable. Because of this difficult
balance, the laws are often complex and hard to
understand.
The widespread perception is that information
privacy laws make it difficult to respond effec-
tively to troubled students. This perception is only
partly correct. Privacy laws can block some
attempts to share information, but even more of-
ten may cause holders of such information to
default to the nondisclosure optioneven when
laws permit the option to disclose. Sometimes this
is done out of ignorance of the law, and sometimes
intentionally because it serves the purposes of the
individual or organization to hide behind the
privacy law. A narrow interpretation of the
law is the least risky course, notwithstanding
the harm that may be done to others if infor-
mation is not shared.
Much of the frustration about privacy laws
stems from lack of understanding. When seen
clearly, the privacy laws contain many provi-
sions that allow for information sharing where
necessary. Also, FERPA and HIPAA are not
consistent (Cook Counseling Center records
come under FERPA, Carilions under HIPAA),
which causes difficulties, as explained below.
This chapter addresses federal and state law
concerning four key categories of information
that may be useful in evaluating and respond-
ing to a troubled student:
Law enforcement records
Court records
Medical information and records
Educational records.
The report also examines a Virginia law that
regulates the process of disclosing informa-
tion. These laws are discussed in the context
of Cho's conduct leading to the shootings of
April 16.
Appendix G summarizes the privacy laws as
background for this chapter, for those un-
familiar with them.
LAW ENFORCEMENT RECORDS
aw enforcement agencies must disclose
certain information to anyone who
requests it.
4
They must disclose basic informa-
tion about felony crimes: the date, location,
general description of the crime, and name of
the investigating officer. Law enforcement
agencies also have to release the name and

4
Va. Code 2.2-3706
W
L
CHAPTER V. INFORMATION PRIVACY LAWS
64
address of anyone arrested and charged with any
type of crime. All records about noncriminal inci-
dents are available upon request. When they dis-
close noncriminal incident records, law enforce-
ment agencies must withhold personally-
identifying information, such as names,
addresses, and social security numbers.
5

Universities with campus police departments
have additional responsibilities. They are required
to maintain a publicly available log that lists all
crimes.
6
The log must give the time, date, and
location of each offense, as well as the disposition
of each case. Under Virginia law, campus police
departments must also ensure that basic informa-
tion about crimes is open to the public.
7
This
includes the name and address of those arrested
for felony crimes against people or property and
misdemeanor crimes involving assault, battery, or
moral turpitude.
8

Most of the detailed information about criminal
activity is contained in law enforcement investiga-
tive files. Under Virginia's Freedom of Informa-
tion Act, law enforcement agencies are allowed to
keep these records confidential. The law also gives
agencies the discretion to release the records.
9

However, law enforcement agencies across the
state typically have a policy against disclosing
such records.
JUDICIAL RECORDS
s a general matter, court records are public
and can be widely disclosed. For the purposes
of responding to troubled students, two types of

5
Law enforcement records regarding juveniles (persons under
18) have special restrictions regarding disclosure. Normally,
they can only be released to other parts of the juvenile justice
system or to parents of an underaged suspect. However, Vir-
ginia law also authorizes, but does not require, law enforce-
ment to share information with school principals about offend-
ers who commit a serious felony, arson, or weapons offense.
Police can tell principals when they believe a juvenile is a sus-
pect or when a juvenile is charged with an offense. After the
case is finished, law enforcement officials can tell principals
the outcome. Va. Code 16.1-301
6
20 U.S.C. 1092(f)(4)(A)
7
Va. Code 23-232.2(B)
8
Va. Code 23-232.2(B)
9
Va. Code 2.2-3706
court proceedings do not fit the general rule:
juvenile hearings and commitment hearings
for involuntary admission.
10

A commitment hearing for involuntary admis-
sion is a hearing where a judicial officer
makes a determination as to whether an indi-
vidual will be committed to a mental health
facility involuntarily. Records of these hear-
ings, which consist of any medical records,
reports of evaluations, and all court docu-
ments, must be sealed when the subject of the
hearing requests it. Tape recordings are made
of the proceedings. The tapes are sealed and
held by court clerks. These records can only be
released by court order.
11

Although their records are confidential, the
hearings themselves must be open to the pub-
lic and certain information about the hearing
is, at least in theory, publicly available.
12
This
would include the name of the subject and the
time, date, and location of the hearing. Of
course, there is no central location where this
information is stored so, as a practical matter,
unless an interested party knew where the
hearing was being held or who was presiding
over it, that person would have a difficult
time uncovering such information. For exam-
ple, Cho's commitment hearing occurred ap-
proximately 12 hours after he was detained.
Logistical difficulties also make it difficult to
visit psychiatric facilities, which are common
locations for commitment hearings. The key,
though, is that the information is public. In
Cho's case, the Virginia Tech Police Depart-
ment (VTPD) was aware that he had been de-
tained pending a commitment hearing. VTPD
could have shared this information with

10
Va. Code 17.1-208 (circuit court records open to the
public). Regarding juvenile court records: under Virginia
law, juvenile court records are even more tightly
restricted than juvenile law enforcement records. Court
records can only be used within the juvenile justice sys-
tem unless a judge orders the records released. Va. Code
16.1-305
11
Va. Code 37.2-818. Cho was the subject of a commit-
ment hearing for involuntary admission on December 14,
2005. The panel obtained the tape recording and records
of this hearing through court order.
12
Va. Code 37.2-820
A
CHAPTER V. INFORMATION PRIVACY LAWS
65
university administration or Cho's parents,
though they did not.
MEDICAL INFORMATION
oth state and federal law govern privacy of
medical information. The federal Health In-
surance and Portability and Accountability Act of
1996 and regulations by the Secretary of Health
and Human Services establish the federal stan-
dards. Together, the law and regulations are
commonly known as HIPAA. Virginia law on
medical information privacy is found in the
Virginia Health Records Privacy Act (VHRPA).
HIPAA and Virginia law have similar standards.
They both state that health information is private
and can only be disclosed for certain reasons.
When specific provisions conflict, HIPAA can pre-
empt a state law, making the state law ineffective.
Generally, this occurs when a state law attempts
to be less protective of privacy than the federal
law or rules.
Both laws apply to all medical providers and bill-
ing entities. They define provider broadly to
include doctors, nurses, therapists, counselors,
social workers, and health organizations such as
HMOs and insurance companies, among others.
Three basic types of disclosures are permitted
under these medical information privacy laws:
Requests made or approved by the person
who is the subject of the records. These
exceptions are based on the idea that the
privacy laws are for the benefit of the per-
son being treated. If the patient asks for
his or her records from a health care pro-
vider or provides written authorization,
the provider must release them.
Disclosure when information must be
shared in order to make medical treat-
ment effective. Medical privacy laws allow
providers to share information with each
other when necessary for treatment pur-
poses.
13
If a medical provider needs to

13
45 C.F.R. 164.506(c)(2); Va. Code 32.1-127.1:03(D)(7)
disclose information to a family mem-
ber, the provider can do so in two
ways. The provider can gain permis-
sion from the patient. Or, in an emer-
gency where the patient is unable to
make such a decision, the provider can
proceed without explicit permission.
14

Situations where privacy is out-
weighed by certain other interests. For
example, providers may sometimes
disclose information about a person
who presents an imminent threat to
the health and safety of individuals
and the public.
15
Providers can also
disclose information to law enforce-
ment in order to locate a fugitive or
suspect.
16
Providers also are author-
ized to disclose information when state
law requires it.
17

Disclosure of information is required by state
law in some situations and is permissible by
HIPAA. An example under Virginia state law
is that Virginia health care providers must
report evidence of child abuse or neglect.
Another type of required disclosure is when
freedom of information laws require public
agencies to disclose their records. If a freedom
of information law requires a public hospital
to disclose information, the disclosure is au-
thorized under HIPAA.
18

EDUCATIONAL RECORDS
rivacy of educational records is primarily
governed by federal law, The Family
Educational Rights and Privacy Act of 1974
and regulations issued by the Secretary of

14
45 C.F.R. 164.510(b)
15
45 C.F.R. 164.512(j)
16
Va. Code 32.1-127.1:03(D)(28)
17
45 C.F.R. 164.512(a), (c)
18
If, however, a state law merely permits disclosure,
HIPAA usually will override state law and prevent dis-
closure. For example, Virginia's Freedom of Information
Act gives public agencies the discretion to release infor-
mation, but does not require information to be released.
Because the decision is left to the discretion of the agency,
HIPAA would prohibit disclosure.
B
P
CHAPTER V. INFORMATION PRIVACY LAWS
66
Education that interpret the law. This law and
the regulations are commonly known as FERPA.
FERPA applies to all educational institutions that
accept federal funding. As a practical matter, this
means almost all institutions of higher learning,
including Virginia Tech. It also includes public
elementary and secondary schools. Like HIPAA,
FERPAs basic rule favors privacy. Information
from educational records cannot be shared unless
authorized by law or with consent of a parent, or if
the student is enrolled in college or is 18 or older,
with that student's consent.
FERPA has special interactions for medical and
law enforcement records. HIPAA also makes an
exception for all records covered by FERPA.
19

Therefore, records maintained by campus health
clinics are not covered by HIPAA.
20
Instead,
FERPA and state law restrictions apply to these
records.
21
FERPA provides the basic requirements
for disclosure of health care records at campus
health clinics, and state law cannot require dis-
closure that is not authorized by FERPA.
22
How-
ever, if FERPA authorizes disclosure, a campus
health clinic would then have to look to state law
to determine whether it could disclose records,
including state laws on confidentiality of medical
records.
For example, Virginia Tech's Cook Counseling
Center holds records regarding Cho's mental
health treatment. On a request for those records,
the center must determine whether the disclosure
is authorized under both FERPA and the Virginia

19
45 C.F.R. 160.103, definition of protected health informa-
tion.
20
U.S. Department of Education, FERPA General Guidance
for Parents, available at
http://www.ed.gov/policy/gen/guid/fpco/ferpa/parents.html
(attached as Appendix H) (June 2007 ED Guidance).
21
The nature of FERPA's application to treatment records has
not been uniformly interpreted (discussed in the Recommen-
dations section). The analysis in this section is based in part
on an official letter sent to the University of New Mexico by
the Family Policy Compliance Office (FPCO). The FPCO is the
part of the Department of Education that officially interprets
FERPA. The letter is included in Appendix G.
22
Letter from LeRoy S. Rooker, Director, Family Compliance
Policy Office, U.S. Department of Education, to Melanie P.
Baise, Associate University Counsel, The University of New
Mexico, dated November 29, 2004 (enclosed as Appendix G).
Health Records Privacy Act. It is important to
note that FERPA was drafted to apply to edu-
cational records, not medical records. Though
it has a small number of provisions about
medical records, FERPA does not enumerate
the different types of disclosures authorized
by HIPAA.
FERPA also has a different scope than
HIPAA. Medical privacy laws such as HIPAA
apply to all informationwritten or oral
gained in the course of treatment. FERPA ap-
plies only to information in student records.
Personal observations and conversations with
a student fall outside FERPA. Thus, for
example, teachers or administrators who wit-
ness students acting strangely are not
restricted by FERPA from telling anyone
school officials, law enforcement, parents, or
any other person or organization.
23
In this
case, several of Cho's professors and the Resi-
dence Life staff observed conduct by him that
raised their concern. They would have been
authorized to call Cho's parents to report the
behavior they witnessed.
Many records kept by university law enforce-
ment agencies also fall outside of FERPA. For
example, it does not apply to records created
and maintained by campus law enforcement
for law enforcement purposes.
24
If campus law
enforcement officers share a record with the
school, however, the copy that is shared
becomes subject to FERPA. For example, in
fall 2005, VTPD received complaints from
female students about Cho's behavior. Their
records of investigation were created for the
law enforcement purpose of investigating a
potential crime. Accordingly, the police could
have told Cho's parents of the incident. When
the universitys Office of Judicial Affairs
requested the records, FERPA rules applied to
the copies held in that office but not to any
record retained by the VTPD.

23
June 2007 ED Guidance (Appendix H).
24
20 U.S.C. 1232g(a)(4)(B)(ii)
CHAPTER V. INFORMATION PRIVACY LAWS
67
Law enforcement performs various other func-
tions that promote public order and safety. For
example, law enforcement officers are usually
responsible for transporting people who are under
temporary detention orders to mental health fa-
cilities. No privacy laws apply to this law
enforcement function. In the Cho case, the VTPD
was not prohibited from contacting the university
administration or Cho's parents to inform them
that Cho was under a temporary detention order
and had been transported to Carilion St. Albans
Behavioral Health.
FERPA authorizes release of information to par-
ents of students in several situations. First, it
authorizes disclosure of any record to parents who
claim adult students as dependents for tax pur-
poses.
25
FERPA also authorizes release to parents
when the student has violated alcohol or drug
laws and is under 21.
26

FERPA generally authorizes the release of infor-
mation to school officials who have been deter-
mined to have a legitimate educational interest in
receiving the information.
27
FERPA also author-
izes unlimited disclosure of the final result of a
disciplinary proceeding that concludes a student
violated university rules for an incident involving
a crime of violence (as defined under federal law)
or a sex offense.
28
Finally, some FERPA excep-
tions regarding juveniles are governed by state
law.
29

FERPA also contains an emergency exception.
Disclosure of information in educational records is
authorized to any appropriate person in connec-
tion with an emergency if the knowledge of such
information is necessary to protect the health or
safety of the student or other persons.
30
Although
this exception does authorize sharing to a

25
20 U.S.C. 1232g(b)(1)(H); 34 C.F.R. 99.31(a)(8)
26
20 U.S.C. 1232g(i)
27
20 U.S.C. 1232g(b)(1)(A); 34 C.F.R. 99.31(a)(1)
28
20 U.S.C. 1232g(b)(6)(B)
29
20 U.S.C. 1232g(b)(1)(E); Va. Code 22.1-287. Virginia
law authorizes disclosure to law enforcement officers seeking
information in the course of his or her duties, court services
units, mental health and medical health agencies, and state or
local children and family service agencies.
30
20 U.S.C. 1232g(b)(1)(I)
potentially broad group of parties, the regula-
tions specifically state that it is to be narrowly
construed. HIPAA, too, contains exceptions
that allow disclosure in emergency situa-
tions.
31
For both laws, the exceptions have
been construed to be limited to circumstances
involving imminent, specific threats to health
or safety. Troubled students may present such
an emergency if their behavior indicates they
are a threat to themselves or others. The
Department of Education's Family Compli-
ance Policy Office (FCPO) has advised that
when a student makes suicidal comments,
engages in unsafe conduct such as playing
with knives or lighters, or makes threats
against another student, the students conduct
can amount to an emergency (see letter in
Appendix G).
32
However, the boundaries of the
emergency exceptions have not been defined
by privacy laws or cases, and these provisions
may discourage disclosure in all but the most
obvious cases.
GOVERNMENT DATA COLLECTION
AND DISSEMINATION PRACTICES
ACT
ne other law on information disclosure
applies to most Virginia government
agencies. The Government Data Collection
and Dissemination Practices Act establishes
rules for collection, maintenance, and dis-
semination of individually-identifying data.
The act does not apply to police departments
or courts. Agencies that are bound by the act
can only disclose information when permitted
or required by law.
33
The attorney general of
Virginia has interpreted permitted by law to
include any official request made by a gov-
ernment agency for a lawful function of the
agency. An agency must inform people who

31
45 C.F.R. 164.512(j); Va. Code 32.1-127.1:03(D)(19);
32.1-127.1:04; 20 U.S.C. 1232g(b)(1)(I)
32
Letter from LeRoy S. Rooker, Director, Family Compli-
ance Policy Office, U.S. Department of Education, to
Superintendent, New Bremen Local Schools, dated
September 24, 1994 (enclosed as Appendix G).
33
Va. Code 2.2-3803(A)(1)
O
CHAPTER V. INFORMATION PRIVACY LAWS
68
give it personal information how it will ordinarily
use and share that information. An agency can
disclose personal information outside of these or-
dinary uses. When it does, however, it must give
notice to the people who provided the informa-
tion.
34
This act was initially used as a reason for
not providing information to the panel until its
authenticity was strengthened by the governors
executive order.
KEY FINDINGS
rganizations and individuals must be able to
intervene in order to assist a troubled student
or protect the safety of other students. Informa-
tion privacy laws that block information sharing
may make intervention ineffective.
At the same time, care must be taken not to
invade a student's privacy unless necessary. This
means there are two goals for information privacy
laws: they must allow enough information sharing
to support effective intervention, and they must
also maintain privacy whenever possible.
Effective intervention often requires participation
of parents or other relatives, school officials,
medical and mental health professionals, court
systems, and law enforcement. The problems pre-
sented by a seriously troubled student often
require a group effort. The current state of infor-
mation privacy law and practice is inadequate to
accomplish this task. The first major problem is
the lack of understanding about the law. The next
problem is inconsistent use of discretion under the
laws. Information privacy laws cannot help stu-
dents if the law allows sharing but agency policy
or practice forbids necessary sharing. The privacy
laws need amendment and clarification. The panel
proposes the following recommendations to
address immediate problems and chart a course
for an effective information privacy system.
RECOMMENDATIONS
V-1 Accurate guidance should be developed
by the attorney general of Virginia regarding

34
Va. Code 2.2-3806(A)(2)
the application of information privacy
laws to the behavior of troubled students.
The lack of understanding of the laws is
probably the most significant problem about
information privacy. Accurate guidance from
the state attorney generals office can alleviate
this problem. It may also help clarify which
differences in practices among schools are
based on a lack of understanding and which
are based on institutional policy. For example,
a representative of Virginia Tech told the
panel that FERPA prohibits the universitys
administrators from sharing disciplinary
records with the campus police department.
The panel also learned that the University of
Virginia has a policy of sharing such records
because it classifies its chief of police as an
official with an educational interest in such
records.
The development of accurate guidance that
signifies that law enforcement officials may
have an educational interest in disciplinary
records could help eliminate discrepancies in
the application of the law between two state
institutions. The guidance should clearly
explain what information can be shared by
concerned organizations and individuals about
troubled students. The guidance should be
prepared and widely distributed as quickly as
possible and written in plain English. Appen-
dix G provides a copy of guidance issued by
the Department of Education in June 2007,
which can serve as a model or starting point
for the development of clear, accurate
guidance.
V-2 Privacy laws should be revised to
include safe harbor provisions. The pro-
visions should insulate a person or organiza-
tion from liability (or loss of funding) for mak-
ing a disclosure with a good faith belief that
the disclosure was necessary to protect the
health, safety, or welfare of the person in-
volved or members of the general public. Laws
protecting good-faith disclosure for health,
safety, and welfare can help combat any bias
toward nondisclosure.
O
CHAPTER V. INFORMATION PRIVACY LAWS
69
V-3 The following amendments to FERPA
should be considered:
FERPA should explicitly explain how it
applies to medical records held for treat-
ment purposes. Although the Department of
Education interprets FERPA as applying to all
such records,
35
that interpretation has not been
universally accepted. Also, FERPA does not
address the differences between medical records
and ordinary educational records such as grade
transcripts. It is not clear whether FERPA pre-
empts state law regarding medical records and
confidentiality of medical information or merely
adds another requirement on top of these records.
FERPA should make explicit an exception
regarding treatment records. Disclosure of
treatment records from university clinics should
be available to any health care provider without
the students consent when the records are needed
for medical treatment, as they would be if covered
under HIPAA. As currently drafted, it is not clear
whether off-campus providers may access the
records or whether students must consent. With-
out clarification, medical providers treating the
same student may not have access to health
information. For example, Cho had been triaged
twice by Cook Counseling Center before being
seen by a provider at Carilion St. Albans in con-
nection with his commitment hearing. Later that
day, he was again triaged by Cook. Carilion St.
Albanss records were governed by HIPAA. Under
HIPAA's treatment exception, Carilion St. Albans
was authorized to share records with Cook. Cooks
records were governed by FERPA. Because
FERPAs rules regarding sharing records for
treatment are unclear about outside entities or
whether consent is necessary, Carilion St. Albans
could not be assured that Cook would share its
records. This situation makes little sense.
V-4 The Department of Education should
allow more flexibility in FERPAa emer-
gency exception. As currently drafted, FERPA
contains an exception that allows for release of
records in an emergency, when disclosure is

35
June 2007 ED Guidance (Appendix H).
necessary to protect the health or safety of
either the student or other people. At first,
this appears to be an exception well-suited to
sharing information about seriously troubled
students. However, FERPA regulations also
state that this exception is to be strictly con-
strued. The strict construction requirement
is unnecessary and unhelpful. The existing
limitations require that an emergency exists
and that disclosure is necessary for health or
safety. Further narrowing of the definition
does not help clarify when an emergency ex-
ists. It merely feeds the perception that non-
disclosure is always a safer choice.
V-5 Schools should ensure that law
enforcement and medical staff (and oth-
ers as necessary) are designated as school
officials with an educational interest in
school records. This FERPA-related change
does not require amendment to law or regula-
tion. Education requires effective intervention
in the lives of troubled students. Intervention
ensures that schools remain safe and students
healthy. University policy should recognize
that law enforcement, medical providers, and
others who assist troubled students have an
educational interest in sharing records. When
confirmed by policy, FERPA should not pre-
sent a barrier to these entities sharing infor-
mation with each other.
V-6 The Commonwealth of Virginia Com-
mission on Mental Health Reform should
study whether the result of a commitment
hearing (whether the subject was volun-
tarily committed, involuntarily commit-
ted, committed to outpatient therapy, or
released) should also be publicly avail-
able despite an individuals request for
confidentiality. Although this information
would be helpful in tracking people going
though the system, it may infringe too much
on their privacy.
As discussed in Chapter IV, and its recom-
mendations to revise Virginia law regarding
the commitment process, the law governing
hearings should explicitly state that basic
CHAPTER V. INFORMATION PRIVACY LAWS
70
information regarding a commitment hearing (the
time, date, and location of the hearing and the
name of the subject) is publicly available even
when a person requests that records remain con-
fidential. This information is necessary to protect
the publics ability to attend commitment hear-
ings.
V-7 The national higher education associa-
tions should develop best practice protocols
and associated training for information
sharing. Among the associations that should
provide guidance to the member institutions are:
American Council on Education (ACE)
American Association of State Colleges
and Universities (AASCU)
American Association of Community Col-
leges (AACE)
National Association of State and Land
Grant Universities and Colleges
(NASLGUC)
National Association of Independent Col-
leges and Universities (NAICU)
Association of American Universities
(AAU)
Association of Jesuit Colleges and Univer-
sities
If the changes recommended above are imple-
mented, it is possible that no further changes to
privacy laws would be necessary, but guidance on
their interpretation will be needed. The unknown
variable is how entities will choose to exercise
their discretion when the law gives them a choice
on whether to share or withhold information. How
an institution uses its discretion can be critically
important to whether it is effectively able to
intervene in the life of a troubled student. For
example, FERPA currently allows schools to
release information in their records to parents
who claim students as dependents. Schools are
not, however, required to release that information.
Yet, if a university adopts a policy against release
to parents, it cuts off a vital source of information.
The history of Seung Hui Cho shows the po-
tential danger of such an approach. During his
formative years, Cho's parents worked with
Fairfax County school officials, counselors,
and outside mental health professionals to
respond to episodes of unusual behavior. Chos
parents told the panel that had they been
aware of his behavioral problems and the con-
cerns of Virginia Tech police and educators
about these problems, they would again have
become involved in seeking treatment. The
people treating and evaluating Cho would
likely have learned something (but not all) of
his prior mental health history and would
have obtained a great deal of information
germane to their evaluation and treatment of
him. There is no evidence that officials at Vir-
ginia Tech consciously decided not to inform
Cho's parents of his behavior; regardless of
intent, however, they did not do so. The ex-
ample demonstrates why it may be unwise for
an institution to adopt a policy barring release
of information to parents.
The shootings of April 16, 2007, have forced
all concerned organizations and individuals to
reevaluate the best approach for handling
troubled students. Some educational institu-
tions in Virginia have taken the opportunity
to examine the difficult choices involved in
attempts to share necessary information while
still protecting privacy. Effort should be made
to identify the best practices used by these
schools and to ensure that these best practices
are widely taught. All organizations and indi-
viduals should be urged to employ their dis-
cretion in appropriate ways, consistent with
the best practices. Armed with accurate guid-
ance, amended laws, and a new sense of direc-
tion, it is an ideal time to establish best prac-
tices for intervening in the life of troubled stu-
dents.

CHAPTER V. INFORMATION PRIVACY LAWS
70 - A
ADDITIONS AND CORRECTIONS
(No changes from original report.).
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71
Chapter VI.
GUN PURCHASE AND CAMPUS POLICIES
n investigating the role firearms played in the
events of April 16, 2007, the panel encoun-
tered strong feelings and heated debate from the
public. The panel's investigation focused on two
areas: Cho's purchase of firearms and ammuni-
tion, and campus policies toward firearms. The
panel recognizes the deep divisions in American
society regarding the ready availability of rapid
fire weapons and high capacity magazines, but
this issue was beyond the scope of this review.
FIREARMS PURCHASES
very person killed at Cho's hands on April
16 was shot with one of two firearms, a
Glock 19 9mm pistol or a Walther P22 .22 caliber
pistol. Both weapons are semiautomatic, which
meant that once loaded, they fire a round with
each pull of the trigger, rather than being able to
fire continuously by holding the trigger down.
Cho purchased the Walther P22 firstby placing
an online order with the TGSCOM, Inc., a com-
pany that sells firearms over the Internet. Cho
then picked up the pistol on February 9, 2007, at
J-N-D Pawn-brokers in Blacksburg, which is
located just across Main Street from the Virginia
Tech campus.
Cho purchased the Glock a month later, on
March 13, from Roanoke Firearms in Roanoke.
Virginia law limits handgun purchases to one
every 30 days, which he may have known judg-
ing by this spacing.
36
Cho made his purchases
using a credit card. Although his parents gave
him money to pay for his expenses, they said
they did not receive his credit card bills and did
not know what he purchased. They stated that
the only time they received an actual billing
statement was after his death, and at that point
the total bill was over $3,000.

36
Va. Code 18.1-308.2:2(P)
On March 22, 2007, shortly after purchasing the
Glock, Cho went to PSS Range and Training, an
indoor pistol range in Roanoke. Cho practiced
shooting for about an hour.
Cho was not legally authorized to purchase his
firearms, but was easily able to do so. Gun pur-
chasers in Virginia must qualify to buy a firearm
under both federal and state law. Federal law
disqualified Cho from purchasing or possessing a
firearm. The federal Gun Control Act, originally
passed in 1968, prohibits gun purchases by any-
one who has has been adjudicated as a mental
defective or who has been committed to a mental
institution.
37
Federal regulations interpreting
the act define adjudicated as a mental defective
as [a] determination by a court, board, commis-
sion, or other lawful authority that a person, as a
result of mental illness [i]s a danger to him-
self or to others.
38
Cho was found to be a danger
to himself by a special justice of the Montgomery
County General District Court on December 14,
2005. Therefore, under federal law, Cho could
not purchase any firearm.
The legal status of Cho's gun purchase under
Virginia law is less clear. Like federal law,
Virginia law also prohibits persons who have
been adjudged incompetent or committed to
mental institutions from purchasing firearms.
39

However, Virginia law defines the terms differ-
ently. It defines incompetency by referring to the
section of Virginia Code for declaring a person
incapable of caring for himself or herself.
40
It
does not specify that a person who had been
found to be a danger to self or others is incom-
petent. Because he had not been declared un-
able to care for himself, it does not appear that
Cho was disqualified under this provision of Vir-
ginia law.

37
18 U.S.C. 922(g)(4)
38
27 C.F.R. 478.11
39
Va. Code 18.2-308.1:2 and 3
40
Va. Code 18.2-308.1:2, citing Va. Code 37.2-1000 et seq.
I
E
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
72
Virginia law also prohibits any person who has
been involuntarily committed pursuant to Article
5 ( 37.2-814 et seq.) of Chapter 8 of Title 37.2
from purchasing or possessing a firearm.
41
This
section authorizes a court to order either in-
patient or outpatient treatment. When a person
is ordered into a hospital, the law is relatively
straightforwardthe person has been involun-
tarily committed. What is not clear from the
statute, however, is whether a person such as
Cho, who was found to be a danger to self or
others and ordered to receive outpatient treat-
ment, qualifies as being involuntarily committed.
Among the mental health community, involun-
tary outpatient commitment is a recognized
term for an order for outpatient treatment. In
practical terms, a person who is found to be an
imminent danger to self or others and ordered
into outpatient treatment is little different than
one ordered into inpatient treatment. However,
the statute does not make clear whether out-
patient treatment is covered. Thus, Cho's right to
purchase firearms under Virginia law was not
clear.
This uncertainty in Virginia law carries over into
the system for conducting a firearms background
check. In general, nationally, before purchasing a
gun from a dealer a person must go through a
background check. A government agency runs
the name of the potential buyer through the
databases of people who are disqualified from
purchasing guns. If the potential purchaser is in
the database, the transaction is stopped. If not,
the dealer is instructed to proceed with the sale.
The agency performing the check varies by state.
Some states rely on the federal government to
conduct the checks. In others, the state and the
federal government both do checks. In yet other
states, such as Virginia, the state conducts the
check of both federal and state databases. In
Virginia the task is given to the state police.
Because purchasers have to be eligible under
both state and federal law, potential buyers in
Virginia have to fill out two forms: the federal
Firearms Transaction Record (ATF 4473) and

41
Va. Code 18.2-308.1:3
the Virginia Firearms Transaction Record (SP
65.) (Copies of the forms are provided in Appen-
dix I.) The forms collect basic information about
the potential buyer, such as name, age, and
social security number. Each form also asks
questions to determine whether a buyer is eligi-
ble to purchase a weapon. Form 4473 asks 11
questions, such as whether the buyer has been
convicted of a felony. SP 65 contains questions
and information regarding Virginia law, such as
whether restraining orders were issued that dis-
qualify purchasers. Firearms dealers initiate the
background check by transmitting information
from the forms to the state polices Firearms
Transaction Program.
Certain firearms transfers do not require back-
ground checks at all. Virginia law does not
require background checks for personal gifts or
sales by private collectors, including transactions
by collectors that occur at gun shows.
In Virginia, the Central Criminal Records
Exchange (CCRE), a division of the state police,
is tasked with gathering criminal records and
other court information that is used for the back-
ground checks. Information on mental health
commitment orders for involuntary admission to
a facility is supposed to be sent to the CCRE by
court clerks, who must send all copies of the or-
ders along with a copy of form SP 237 that pro-
vides basic information about the person who is
the subject of the order.
42
As currently drafted,
the law only requires a clerk to certify a form,
and does not specify who should complete the
form. Because of the lack of clarity, it was
reported to the panel that clerks in some juris-
dictions do not send the information unless they
receive a completed form. Recommendations to
improve this aspect of the law were given in
Chapter IV.
The meaning of the term admission to a facility
is less clear than it might seem. The law appears
on an initial reading to only include orders
requiring a person to receive inpatient care. This
reading seems to have support from the Virginia

42
Va. Code 37.2-819
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
73
involuntary commitment statute. That law uses
admission to a facility when describing in-
patient treatment, not outpatient treatment.
43

But the law is actually more complex. Laws
about mental health commitment and sending
orders to CCRE all appear in Title 37.2 of the
Virginia Code. The definitions for that title state
that facility means a state or licensed hospital,
training center, psychiatric hospital, or other
type of residential or outpatient mental health or
mental retardation facility.
44
So while the most
obvious reading of the law is that only inpatient
orders should be sent to CCRE, the actual
requirement is unclear.
At the time Cho purchased his weapons, the gen-
eral understanding was that only inpatient
orders had to be sent to CCRE. Probably due to
this understanding, the special justices Decem-
ber 14, 2005, order finding Cho to be a danger to
himself was not reported to the firearms back-
ground check system. Although the law may
have been ambiguous, the checking process was
not. Either you are or are not in the database
when a gun purchase request form is submitted,
and Cho was not.
There does not seem to have been an apprecia-
tion in setting up this process that the federal
mental health standards were different than
those of the state or that the practice deprived
the federal database of information it needed in
order to make the system effective. Thus on Feb-
ruary 9 and March 13, 2007, Cho, a person dis-
qualified under federal law from purchasing a
firearm, walked into two licensed firearms deal-
ers. He filled out the required forms. The dealers
entered his information into the background
check system. Both checks told the dealers to
proceed with the transaction. Minutes after both
checks, Cho left the stores in possession of semi-
automatic pistols.

43
Va. Code 37.2-817. Paragraph B describes inpatient
orders and uses the term admitted to a facility; paragraph
C authorizes outpatient commitment but does not use the
term admitted to a facility.
44
Va. Code. 37.2-100
The FBI indicated in a press release dated April
19, 2007, that just 22 states reported any mental
health information to the federal database.
Ironically, the FBI cited Virginia as the state
that provided the most information on people
disqualified due to mental deficiency.
45

In the days following the killings at Virginia
Tech, Governor Kaine moved to clarify the law
regarding inclusion of outpatient treatment into
the database. Executive Order 50 now requires
executive branch employees, including the state
police, to collect information on outpatient orders
and to treat such orders as disqualifications to
owning a firearm. The state police revised SP
237 to ensure that they receive information
regarding out-patient orders. Copies of the older
and revised versions of SP 237 are presented in
Appendix J. As previously discussed in Chapter
IV, the panel recommends that the General
Assembly clarify the relevant laws in this regard
to permanently reflect the interpretation of
Executive Order 50.
It is not clear whether Cho knew that he was
prohibited from purchasing firearms. ATF 4473
asks each potential purchaser [h]ave you ever
been adjudicated mentally defective (which
includes having been adjudicated incompetent to
manage your own affairs) or have you ever been
committed to a mental institution? The state
and federal forms that Cho filled out are cur-
rently held by the Virginia state police in their
case investigation file, but were destroyed in the
CCRE file, as required after 30 days. The state
police did not permit the panel to view copies of
the forms in their investigation file but indicated
that Cho answered no to this question on both
forms. It is impossible to know whether Cho
understood that the proper response was yes
and whether his answers were mistakes or delib-
erate falsifications. In any event, the fact
remains that Cho, a person disqualified from
purchasing firearms, was readily able to obtain
them.

45
The panel notes that the federal law terminology referring
to mentally ill persons as mentally defective is outmoded
based on current medical and societal understanding of men-
tal health.
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
74
AMMUNITION PURCHASES
ho purchased ammunition on several occa-
sions in the weeks and months leading up to
the shootings. On March 13, 2007, he purchased
a $10 box of practice ammunition from Roanoke
Firearms at the same time he bought his Glock
9mm pistol. On March 22 and 23, he purchased a
total of five 10-round magazines for the Walther
on the Internet auction site eBay. In addition,
Cho purchased several 15-round magazines
along with ammunition and a hunting knife on
March 31 and April 1 at local Wal-Mart and
Dick's Sporting Goods stores. With these maga-
zines loaded, Cho would be able to fire 15 rounds,
eject the magazine, and load a fresh one in a
matter a moments. By the time he walked into
Norris Hall, Cho had almost 400 bullets in maga-
zines and loose ammunition.
Federal law prohibited Cho from purchasing
ammunition. Just as it prohibits anyone from
purchasing a gun who has been found to be a
danger to self or others, it prohibits the same
individuals from buying ammunition.
46
However,
unlike firearms, there is no background check
associated with purchasing ammunition. Neither
does Virginia law place any restrictions on who
can purchase ammunition. It does prohibit the
use of some types of ammunition while commit-
ting a crime, but does not regulate the purchase
of such ammunition.
47
Cho did not use any spe-
cial types of ammunition that are restricted by
law.
The panel also considered whether the previous
federal Assault Weapons Act of 1994 that banned
15-round magazines would have made a differ-
ence in the April 16 incidents. The law lapsed
after 10 years, in October 2004, and had banned
clips or magazines with over 10 rounds. The
panel concluded that 10-round magazines that
were legal would have not made much difference
in the incident. Even pistols with rapid loaders
could have been about as deadly in this situation.

46
18 U.S.C 922(d)(4)
47
Va. Code 18.2-308.3
GUNS ON CAMPUS
irginia Tech has one of the tougher policy
constraints of possessing guns on campus
among schools in Virginia. However, there are no
searches of bags or use of magnetometers on
campus like there are in government offices or
airports. Cho carried his weapons in violation of
university rules, and probably knew that it was
extremely unlikely that anyone would stop him
to check his bag. He looked like many others.
Virginia universities and colleges do not seem to
be adequately versed in what they can do about
banning guns on campus under existing inter-
pretations of state laws. The governing board of
colleges and universities can set policies on car-
rying guns. Some said their understanding is
that they must allow anyone with a permit to
carry a concealed weapon on campus. Others
said they thought guns can be banned from
buildings but not the grounds of the institution.
Several major universities reported difficulty
understanding the rules based on their lawyers
interpretation. Most believe they can set rules
for students and staff but not the general public.
Virginia Tech, with approval of the state Attor-
ney Generals Office, had banned guns from cam-
pus altogether.
This issue came to a head at one of the panels
public meetings held at George Mason Univer-
sity. It was known that many advocates of the
right to carry concealed weapons on campus were
planning to attend the meeting carrying weapons
to make a point. GMU did not know they could
have established a policy to stop the weapons
from being carried into their buildings.
The Virginia Tech total gun ban policy was insti-
tuted a few years ago when it was accidentally
discovered that a student playing the role of a
patient in a first aid drill was carrying a con-
cealed weapon. That student, now a Virginia
Tech graduate with a masters degree in engi-
neering, stated to the panel that he started car-
rying a weapon after witnessing assaults and
hearing about other crimes on the Virginia Tech
campus. He and other students told the panel
C V
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
75
that they felt it was safer for responsible people
to be armed so they could fight back in exactly
the type of situation that occurred on April 16.
They might have been able to shoot back and
protect themselves and others from being injured
or killed by Cho. The guns-on-campus advocates
cited statistics that overall there are fewer kill-
ings in environments where people can carry
weapons for self-defense. Of course if numerous
people had been rushing around with handguns
outside Norris Hall on the morning of April 16,
the possibility of accidental or mistaken shoot-
ings would have increased significantly. The
campus police said that the probability would
have been high that anyone emerging from a
classroom at Norris Hall holding a gun would
have been shot.
Data on the effect of carrying guns on campus
are incomplete and inconclusive. The panel is
unaware of any shootings on campus involving
people carrying concealed weapons with permits
to do so. Likewise, the panel knows of no case in
which a shooter in campus homicides has been
shot or scared off by a student or faculty member
with a weapon. Written articles about a campus
shooting rarely if ever comment on permits for
concealed weapons, so this has been difficult to
research. It may have happened, but the num-
bers of shootings on campuses are relatively
fewabout 16 a year at approximately 4,000 col-
leges and universities, according to the U.S.
Department of Education Campus Crime Statis-
tics for 20022004. It could be argued that if
more people carried weapons with permits, the
few cases of shootings on campus might be
reduced further.
On the other hand, some students said in their
remarks to the panel that they would be uncom-
fortable going to class with armed students sit-
ting near them or with the professor having a
gun. People may get angry even if they are sane,
law-abiding citizens; for example, a number of
police officers are arrested each year for assaults
with weapons they carry off duty, as attested to
by stories in daily newspapers and other media.
Campus police chiefs in Virginia and many chief-
level officers in the New York City region who
were interviewed voiced concern that as the
number of weapons on campuses increase, sooner
or later there would be accidents or assaults
from people who are intoxicated or on drugs who
either have a gun or interact with someone who
does. They argued that having more guns on
campus poses a risk of leading to a greater num-
ber of accidental and intentional shootings than
it does in averting some of the relatively rare
homicides. (See Appendix K for an article about
the recent discharge of a gun by someone intoxi-
cated in a fraternity house. Although a benign
incident, it illustrates the concern.)
The panel heard a presentation from Dr. Jerald
Kay, the chair of the committee on college men-
tal health of the American Psychiatric Associa-
tion about the large percentage of college stu-
dents who binge drink each year (about 44 per-
cent), and the surprisingly large percentage of
students who claim they thought about suicide
(10 percent). College years are full of academic
stress and social stress. The probability of dying
from a shooting on campus is smaller than the
probability of dying from auto accidents, falls, or
alcohol and drug overdoses.
KEY FINDINGS
ho was able to purchase guns and ammuni-
tion from two registered gun dealers with no
problem, despite his mental history.
Cho was able to kill 31 people including himself
at Norris Hall in about 10 minutes with the
semiautomatic handguns at his disposal. Having
the ammunition in large capacity magazines
facilitated his killing spree.
There is confusion on the part of universities as
to what their rights are for setting policy regard-
ing guns on campus.
C
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
76
RECOMMENDATIONS
VI-1 All states should report information
necessary to conduct federal background
checks on gun purchases. There should be
federal incentives to ensure compliance. This
should apply to states whose requirements are
different from federal law. States should become
fully compliant with federal law that disqualifies
persons from purchasing or possessing firearms
who have been found by a court or other lawful
authority to be a danger to themselves or others
as a result of mental illness. Reporting of such
information should include not just those who
are disqualified because they have been found to
be dangerous, but all other categories of disquali-
fication as well. In a society divided on many gun
control issues, laws that specify who is prohib-
ited from owning a firearm stand as examples of
broad agreement and should be enforced.
VI-2 Virginia should require background
checks for all firearms sales, including
those at gun shows. In an age of widespread
information technology, it should not be too diffi-
cult for anyone, including private sellers, to con-
tact the Virginia Firearms Transaction Program
for a background check that usually only takes
minutes before transferring a firearm. The pro-
gram already processes transactions made by
registered dealers at gun shows. The practice
should be expanded to all sales. Virginia should
also provide an enhanced penalty for guns sold
without a background check and later used in a
crime.
VI-3 Anyone found to be a danger to them-
selves or others by a court-ordered review
should be entered in the Central Criminal
Records Exchange database regardless of
whether they voluntarily agreed to treat-
ment. Some people examined for a mental illness
and found to be a potential threat to themselves
or others are given the choice of agreeing to men-
tal treatment voluntarily to avoid being ordered
by the courts to be treated involuntarily. That
does not appear on their records, and they are
free to purchase guns. Some highly respected
people knowledgeable about the interaction of
mentally ill people with the mental health sys-
tem are strongly opposed to requiring voluntary
treatment to be entered on the record and be
sent to a state database. Their concern is that it
might reduce the incentive to seek treatment
voluntarily, which has many advantages to the
individuals (e.g., less time in hospital, less
stigma, less cost) and to the legal and medical
personnel involved (e.g., less time, less paper-
work, less cost). However, there still are powerful
incentives to take the voluntary path, such as a
shorter stay in a hospital and not having a re-
cord of mandatory treatment. It does not seem
logical to the panel to allow someone found to be
dangerous to be able to purchase a firearm.
VI-4 The existing attorney generals opinion
regarding the authority of universities and
colleges to ban guns on campus should be
clarified immediately. The universities in Vir-
ginia have received or developed various inter-
pretations of the law. The Commonwealths at-
torney general has provided some guidance to
universities, but additional clarity is needed
from the attorney general or from state legisla-
tion regarding guns at universities and colleges.
VI-5 The Virginia General Assembly should
adopt legislation in the 2008 session clearly
establishing the right of every institution of
higher education in the Commonwealth to
regulate the possession of firearms on cam-
pus if it so desires. The panel recommends that
guns be banned on campus grounds and in build-
ings unless mandated by law.
VI-6 Universities and colleges should make
clear in their literature what their policy is
regarding weapons on campus. Prospective
students and their parents, as well as university
staff, should know the policy related to concealed
weapons so they can decide whether they prefer
an armed or arms-free learning environment.
CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES
76 - A
ADDITIONS AND CORRECTIONS
Testimony on Shooting Incidence on Campuses: p. 75, Clarification A question was
received on the relevancy of testimony by Dr. Jerald Kay on the frequency of shootings on cam-
puseswhether its inclusion was an attempt to downplay the seriousness of the Virginia Tech
shootings in light of other dangers to students such as drunk driving.
The Review Panel invited Dr. Kays presentation for two reasons: First to consider the risk
from guns as part of the larger picture of campus emergency planning. The Review Panel
wanted colleges and universities to consider, as part of emergency planning, the whole range of
threats and their likelihood, not just guns. Second, this testimony was of interest as part of the
discussion of whether guns should be allowed to be carried on campuses. The frequency and
nature of shootings on campus was very relevant to the deliberations of the Review Panel in
making recommendations regarding these issues. It also was relevant in understanding the
risk of a further shooting faced by the Policy Group after the double homicide.
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77
Chapter VII.
DOUBLE MURDER AT WEST AMBLER JOHNSTON
his chapter discusses the double homicide at
West Ambler Johnston (WAJ) residence hall
and the police and university actions taken in
response. It covers the events up to the shootings
in Norris Hall, which are presented in the next
chapter.
APPROACH AND ATTACK
ho left his dormitory early in the morning of
April 16, 2007 and went to the WAJ, about a
2-minute walk. He was seen outside WAJ by a
student about 6:45 a.m. Figure 3 shows the exte-
rior of WAJ and Figure 4, a typical hallway
inside WAJ.

Figure 3. Exterior of West Ambler Johnston
Because Chos student mailbox was located in
the lobby of WAJ, he had access to that dormi-
tory with his pass card, but only after 7:30 a.m.
Cho somehow gained entrance to the dormitory,
possibly when a student coming out let him in or
by tailgating someone going in. (No one remem-
bers having done so, or admits it.)
Cho went to the fourth floor by either stairway or
elevator to the room of student Emily Hilscher.

Figure 4. Hallway Outside Dorm Rooms in
West Ambler Johnston
She had just returned with her boyfriend, a stu-
dent at Radford University who lived in Blacks-
burg. He drove her back to her dorm, saw her
enter, and drove away. She entered at 7:02 a.m.,
based on swipe card records, which also showed
that she used a different entrance than Cho did.
Although it is known that Cho previously stalked
female students, including one in WAJ on her
floor, the police have found no connection
between Cho and Hilscher from any written
materials, dorm mates, other friends of his or
hers, or any other source.
As of this writing, the police still had found no
motive for the slaying.
T
C
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
78
Figure 5. Typical Dorm Room in Ambler Johnston Hall
Not long after 7:15 a.m., noises emanating from
Hilschers room were loud enough and of such a
disturbing nature that resident advisor Ryan
Clark, who lived next door, checked to see what
was happening. The presumption is that he
came to investigate, saw Cho, and was killed to
stop any interference with the shooter and his
identification. Both Hilscher and Clark were
shot by Cho at close range. (Figure 5 shows a
typical dorm room in WAJ.)
The sounds of the shots or bodies falling were
misinterpreted by nearby students as possibly
someone falling out of a loft bed, which had
happened before. A student in a nearby room
called the Virginia Tech Police Department
(VTPD), which dispatched a police officer and an
emergency medical service (EMS) team
standard protocol for this type of call. The police
received the call at 7:20 a.m. and arrived out-
side at 7:24 a.m. (an EMS response under 5
minutes for dispatch plus travel time is better
than average, even in a city).
48
The EMS team
arrived on scene at 7:26 and at the dorm room
at 7:29. As soon as the police officer arrived and
saw the gunshot wounds, he called for addi-
tional police assistance. Hilscher was trans-
ported to Montgomery Regional Hospital where

48
This is based on data from 150 TriData studies of fire and
EMS departments over 25 years. The National Fire Protec-
tion Association standard calls for a fire or EMS response in
5 minutes (1 minute turnout time, 4 minutes travel time) in
90 percent of calls, but few agencies meet that objective.
she received care, and then transferred to Caril-
ion Roanoke Memorial Hospital where she died.
Clark was treated en route to Montgomery Re-
gional Hospital, but could not be resuscitated by
the emergency medical technicians (EMTs) and
was pronounced dead shortly after arrival at the
hospital. Their wounds were considered nonsur-
vivable at the time and in retrospect.
In the meantime, Cho somehow exited the build-
ing. No one reported seeing him leaving, accord-
ing to police interviews of people in the dorm at
the time. His clothes and shoes were bloodied,
and he left bloody footprints in and coming out
of the room. His clothes were found later in his
room. Students were getting ready for 8:00 a.m.
classes, but no one reported seeing Cho. Figure
6 shows the door to Hilschers dorm room, with
a peephole typical of others on that floor.
When Chief Wendell Flinchum of the VTPD
learned of the incident at 7:40 a.m., he called for
additional resources from the Blacksburg Police
Department (BPD). A detective for investigation
and an evidence technician headed for the
scene. Chief Flinchum notified the office of the
executive vice president at 7:57 a.m., after ob-
taining more information on what was found.
Immediately after they arrived, police started
interviewing students in the rooms near
Hilschers room, and essentially locked down the
building, with police inside and outside. (The
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
79
Figure 6. Emily Hilschers Door With Peephole
exterior dorm doors were still locked from the
usual nighttime routine.) A female friend of
Hilscher came to the dorm to accompany her to
class, as was their common practice, and she
was immediately questioned by the police. She
reported that Hilscher had been visiting her
boyfriend, knew of no problems between them,
and that Hilschers boyfriend owned a gun and
had been practicing on a target range with it.
She knew his name and the description of his
vehicle and that he usually drove her back to
the dorm. The boyfriend was immediately con-
sidered a person of interest.
49
Because he had
been the last known person to see her before the
shooting, he was the natural starting point for
an investigation. No one had seen him drop her
off. (The fact that he had dropped her off was
established more than an hour later, after he
was questioned.) The police then sent out a
BOLO (be on the lookout) alert for his pickup

49
Person of interest means someone who might be a sus-
pect or might have relevant information about a crime.
truck and searched for it in the campus parking
lots but could not find it. This implied that the
only known person of interest had likely left the
campus. There were no other leads at that time.
The police had no evidence other than shell cas-
ings in the room, the footprints, and the victims.
The VTPD police chief said that this murder
might have taken a long time to solve, if ever,
for lack of evidence and witnesses. After the
second incident occurred, the gun was identified
by ATF as having been the same one used in the
first shooting, but that was hindsight. If Cho
had stopped after the first two shootings, he
might well have never been caught.
PREMATURE CONCLUSION?
t this point, the police may have made an
error in reaching a premature conclusion
that their initial lead was a good one, or at least
in conveying that impression to the Virginia
Tech
administration. While continuing their investi-
gation, they did not take sufficient action to deal
with what might happen if the initial lead
proved false. They conveyed to the university
Policy Group that they had a good lead and that
the person of interest was probably not on cam-
pus. (That is how the Policy Group understood
it, according to its chair and other members who
were interviewed by the panel and who pre-
sented information at one of its open hearings.)
After two people were shot dead, police needed
to consider the possibility of a murderer loose on
campus who did a double slaying for unknown
reasons, even though a domestic disturbance
was a likely possibility. The police did not urge
the Policy Group to take precautions, as best
can be understood from the panels interviews.
It was reasonable albeit wrong that the VTPD
thought this double murder was most likely the
result of a domestic argument , given the facts
they had initially, including the knowledge that
the last person known to have been with the
female victim was her boyfriend who owned a
gun and cared greatly for her, according to
police interviews, plus the fact that she was shot
A
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
80
with a young man in her room under the cir-
cumstances found.
There are very few murders each year on cam-
pusesan average of about 16 across 4,000 uni-
versities and colleges, as previously noted. The
only college campus mass murder in the United
States in the past 40 years was the University
of Texas tower sniper attack, though there have
been occasional multiple murders. Based on
past history, the probability of more shootings
following a dormitory slaying was very low. The
panel researched reports of multiple shootings
on campuses for the past 40 years, and no sce-
nario was found in which the first murder was
followed by a second elsewhere on campus. (See
Appendix L for a summary of the multiple
criminal shootings on campus.) The VTPD had
the probabilities correct, but needed to consider
the low-probability side as well as the most
likely situation.
Both the VTPD and the BPD immediately put
their emergency response teams (ERTs) (i.e.,
SWAT teams) on alert and staged them at loca-
tions from which they could respond rapidly to
the campus or city. They also had police on
campus looking for the gunman while they pur-
sued the boyfriend. The ERTs were staged
mainly in case they had to make an arrest of the
gunman or serve search warrants on the shoot-
ing suspect.
DELAYED ALERT TO UNIVERSITY
COMMUNITY
he VTPD chief and BPD chief both
responded to the murder scene in minutes.
Chief Flinchum of the VTPD arrived at 8:00
a.m. and Chief Crannis of the BPD arrived at
8:13 a.m. As noted above, the VTPD chief had
notified the university administration of the
shootings at 7:57 a.m., just before he arrived at
the scene.
Once informed, the university president almost
immediately convened the emergency Policy
Group to decide how to respond, including how
and when to notify the university community. In
an interview with President Steger, members of
the panel were told that the police reports to the
Policy Group first described a possible murder
suicide and then a domestic dispute, and that
the police had identified a suspect. After the
area parking lots had been searched, the police
reported the suspect probably had left the cam-
pus.
The police did not tell the Policy Group that
there was a chance the gunman was loose on
campus or advise the university of any immedi-
ate action that should be taken such as cancel-
ing classes or closing the university. Also, the
police did not give any direction as to an emer-
gency message to be sent to the students. The
police were very busy at WAJ investigating
what had happened, gathering evidence, and
managing the scene. They were conveying in-
formation by phone to the Policy Group at this
point. Not until 9:25 a.m. did the police have a
representative sitting with the Policy Group, a
police captain.
The VTPD has the authority under the Emer-
gency Response Plan and its interpretation in
practice to request that an emergency message
be sent, but as related in Chapter II, the police
did not have the capability to send a message
themselves. That capability was in the hands of
the associate vice president for University
Affairs and one other official. As stated earlier,
the VTPD is not a member of the Policy Group
but is often invited to attend Policy Group meet-
ings dealing with the handling of emergencies.
One of the factors prominent in the minds of the
Policy Group, according to the university presi-
dent and others who were present that day, was
the experience gained the previous August when
a convict named William Morva escaped from a
nearby prison and killed a law enforcement offi-
cer and a guard at a local hospital. Police
reported he might be on the VT campus. The
campus administration issued an alert that a
murderer was on the loose in the vicinity of the
campus. Then a female employee of the bank in
the Squires Student Activities Center reportedly
called her mother on a cell phone, and the
T
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
81
mother incorrectly inferred that people were
being held hostage in the student center. The
mother called the police, who responded with a
SWAT team. News photos of the event show
students rushing out of the building with their
hands up while police with drawn automatic
weapons and bulletproof vests were charging
into the building, a potentially dangerous situa-
tion. It was a false alarm. Morva was captured
off campus, but this situation was fresh in the
minds of the Policy Group as it met to decide
what to do on the report of the double homicide
at WAJ. It is questionable whether there was
any panic among the students in the Morva
incident, as some reports had it, and how dan-
gerous that situation really was, but the Policy
Group remembered it as a highly charged and
dangerous situation. In the eyes of the Policy
Group, including the university president, a
dangerous situation had been created by their
warning in that August 2006 event coupled with
the subsequent spread of rumors and misinfor-
mation. The Policy Group did not want to cause
a repeat of that situation if the police had a sus-
pect and he was thought to be off campus.
Even with the police conveying the impression
to campus authorities that the probable perpe-
trator of the dormitory killings had left campus
and with the recent past history of the panic
caused by the alert 9 months earlier, the uni-
versity Policy Group still made a questionable
decision. They sent out a carefully worded alert
an hour and half after they heard that there
was a double homicide, which was now more
than 2 hours after the event.
Vice Provost of Student Affairs David Ford pre-
sented a statement to the panel on May 21,
2007. He was a member of the university Policy
Group that made the decisions on what to do
after hearing about the shootings.
Shortly after 8:00 a.m. on Monday, April
16, I was informed that there had been a
shooting in West Ambler Johnston hall and
that President Steger was assembling the
Policy Group immediately. By approxi-
mately 8:30 a.m., I and the other members
of the group had arrived at the Burruss
Hall Boardroom and Dr. Steger convened
the meeting. I learned subsequently that as
he awaited the arrival of other group mem-
bers, President Steger had been in regular
communication with the police, had given
direction to have the governor's office noti-
fied of the shooting, and had called the
head of University Relations to his office to
begin planning to activate the emergency
communication systems.
When he convened the meeting, President
Steger informed the Policy Group that
Virginia Tech police had received a call at
approximately 7:20 a.m. on April 16, 2007,
to investigate an incident in a residence
hall room in West Ambler Johnston.
Within minutes of the call, Virginia Tech
police and Virginia Tech Rescue Squad
members responded to find two gunshot
victims, a male and a female, inside a room
in the residence hall. Information contin-
ued to be received through frequent tele-
phone conversations with Virginia Tech
police on the scene. The Policy Group was
informed that the residence hall was being
secured by Virginia Tech police, and stu-
dents within the hall were notified and
asked to remain in their rooms for their
safety. We were further informed that the
room containing the gunshot victims was
immediately secured for evidence collec-
tion, and Virginia Tech police began ques-
tioning hall residents and identifying
potential witnesses. In the preliminary
stages of the investigation, it appeared to
be an isolated incident, possibly domestic
in nature. The Policy Group learned that
Blacksburg police and Virginia state police
had been notified and were also on the
scene.
The Policy Group was further informed by
the police that they were following up on
leads concerning a person of interest in
relation to the shooting. During this 30-
minute period of time between 8:30 and
9:00 a.m., the Policy Group processed the
factual information it had in the context of
many questions we asked ourselves. For
instance, what information do we release
without causing a panic? We learned from
the Morva incident last August that specu-
lation and misinformation spread by indi-
viduals who do not have the facts cause
panic. Do we confine the information to
students in West Ambler Johnston since
2
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
82
the information we had focused on a single
incident in that building? Beyond the two
gunshot victims found by police, was there
a possibility that another person might be
involved (i.e., a shooter), and if so, where is
that person, what does that person look
like, and is that person armed? At that
time of the morning, when thousands are
in transit, what is the most effective and
efficient way to convey the information to
all faculty, staff, and students? If we
decided to close the campus at that point,
what would be the most effective process
given the openness of a campus the size of
Virginia Tech? How much time do we have
until the next class change?
And so with the information the Policy
Group had at approximately 9 a.m., we
drafted and edited a communication to be
released to the university community via
e-mail and to be placed on the university
web site. We made the best decision we
could based upon the information we had
at the time. Shortly before 9:30 a.m., the
Virginia Tech communityfaculty, staff,
and studentswere notified by e-mail as
follows:
"A shooting incident occurred at West
Ambler Johnston earlier this morning.
Police are on the scene and are investigat-
ing. The university community is urged to
be cautious and are asked to contact
Virginia Tech Police if you observe anything
suspicious or with information on the case.
Contact Virginia Tech Police at 2316411.
Stay tuned to the www.vt.edu. We will post
as soon as we have more information
The Virginia Tech Emergency/Weather
Line recordings were also transmitted and
a broadcast telephone message was made
to campus phones. The Policy Group
remained in session in order to receive
additional updates about the West Ambler
Johnston case and to consider further
actions if appropriate.
No mention was made in the initial message
sent to the students and staff of a double mur-
der, just a shooting, which might have implied
firing a gun and injuries, possibly accidental,
rather than two murdered. Students and faculty
were advised to be alert. The message went out
to e-mails and phones. Some students and fac-
ulty saw the alert before the second event but
many, if not most, did not see it, nor did most in
Norris Hall classes. Those who had 9:05 a.m.
classes were already in them and would not
have seen the message unless checking their
computers, phone, or Blackberries in class. If
the message had gone out earlier, between 8:00
and 8:30 a.m., more people would have received
it before leaving for their 9:05 a.m. classes. If an
audible alert had been sounded, even more
might have tuned in to check for an emergency
message.
Few anywhere on campus seemed to have acted
on the initial warning messages; no classes were
canceled, and there was no unusual absentee-
ism. When the Norris Hall shooting started, few
connected it to the first message.
The university body was not put on high alert
by the actions of the university administration
and was largely taken by surprise by the events
that followed. Warning the students, faculty,
and staff might have made a difference. Putting
more people on guard could have resulted in
quicker recognition of a problem or suspicious
activity, quicker reporting to police, and quicker
response of police. Nearly everyone at Virginia
Tech is adult and capable of making decisions
about potentially dangerous situations to safe-
guard themselves. So the earlier and clearer the
warning, the more chance an individual had of
surviving.
DECISION NOT TO CANCEL CLASSES
OR LOCK DOWN
any people have raised the question of
whether the university should have been
locked down. One needs to analyze the feasibil-
ity of doing this for a campus of 35,000 people,
and what the results would have been even if
feasible. Most police chiefs consulted in this
review believe that a lockdown was not feasible.
When a murder takes place in a city of 35,000
population, the entire city is virtually never
shut down. At most, some in the vicinity of the
shooting might be alerted if it is thought that
M
3
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
83
the shooter is in the neighborhood. People might
be advised by news broadcast or bullhorns to
stay inside. A few blocks might be cordoned off,
but not a city of 35,000. A university, however,
in some ways has more control than does the
mayor or police of a city, so the analogy to a city
is not entirely fitting. The university is also con-
sidered by many as playing a role in loco
parentis for at least some of its students, even
those who are legally adults, a view shared by
several victims families.
President Steger noted that closing the univer-
sity in an emergency presents another problem,
traffic congestion. In the Morva incident, when
the school was closed, it took over an hour and a
half for the traffic to clear despite trying to
stage the evacuation. Numerous people also
stood waiting for buses. Those evacuating were
very vulnerable in their cars and at bus stops.
Some people suggested that the university
should have closed out of respect for the two
students who were killed. However, the general
practice at most large universities is not to close
when a student dies, regardless of the cause
(suicide, homicide, traffic accident, overdose,
etc.). Universities and colleges need to make
that decision based on individual criteria.
Feasibility A building can be locked down in
the sense of locking the exterior doors, barring
anyone from coming or going. Elementary
schools practice that regularly, and so do some
intermediate and high schools. At least some
schools in Blacksburg were locked down for a
while after the first shootings. Usually, a lock-
down also implies locking individual classrooms.
Virginia Tech does not have locks on the inside
of classroom doors, as is the case for most uni-
versities and many high schools.
The analogy to elementary or high schools, how-
ever, is not very useful. The threat in elemen-
tary schools usually is not from students, the
classrooms have locks, they have voice commu-
nication systems to teachers and students, and
the people at risk are in one building, not 131
buildings. High schools usually have one build-
ing and some of the other characteristics too.
A message could theoretically be sent to all
buildings on campus to lock their doors, but
there was no efficient way to do this at Virginia
Tech. It would have required calls or e-mails to
individuals who had the ability to lock the doors
for at least 131 buildings or sending people on
foot to each building. E-mails might have been
used, but one could not be sure they would be
read promptly. Even if people in the buildings
received a message by phone or e-mail, the uni-
versity had no way of knowing who received the
message without follow up calls or requesting
returned responses to the calls and e-mails. The
process was complicated and would have taken
considerable time.
Some university campuses, mostly urban ones,
have guards at every entrance to their build-
ings. Virginia Tech does not. It would take ap-
proximately 450500 guards to post one at all
entrances of all major buildings on the VT cam-
pus.
50
The VTPD at full strength has 41 officers,
of which only 14 are on-duty at 8:00 a.m. on a
weekday, 5 on patrol and 9 in the office includ-
ing the chief. It is unlikely all VT buildings
could be guarded or closed within 12 hours af-
ter the first shooting.
Closing all of the roads into the school would
also be a problem. The large campus includes 16
vehicle entrances separated in some cases by a
mile from each other. More police can be
brought in from Blacksburg and other areas.
Without a clear emergency, however, it is incon-
ceivable that large numbers of police would rush
to the campus, leaving non-campus areas at risk
from the same gunman and all other crimes
when it was not expected to be more than an
isolated incident.
There are no barriers to pedestrians walking
across lawns into the campus. It would have
taken hundreds of police, National Guard
troops, or others to truly close down the campus,
and they could not have arrived in time.

50
There are about 30 dorm-type buildings with an average
of about two entrances each, and 100 class-
room/administration buildings with an average of about four
entrances each, for an estimated total of about 460.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
84
Messages might have been prioritized to reach
the buildings with the most people and to guard
them first, but it still was impractical and not
seriously considered. All police with whom the
panel consulted felt that a lockdown for a cam-
pus like Virginia Tech was not feasible on the
morning of April 16.
More feasible would have been canceling classes
and asking everyone to stay home or stay
indoors until an all-clear was given, although
even getting that message to everyone quickly
was problematical with the new emergency
alerting system not totally in place. Students
could have been asked to return to their dormi-
tories or to housing off campus. However, many
might have gone to other public buildings on
campus unless those buildings also were
ordered to close. Canceling classes and getting a
message out to students off campus would have
stopped some from coming onto the campus. But
students still could congregate vulnerably in
dorms or other places.
Furthermore, the police and university did not
know whether the gunman was inside or outside
WAJ or other buildings. People not in buildings,
typically numbering in the thousands outdoors
on the campus at a given time, may seek refuge
in buildings in the face of an emergency. With-
out knowing where the gunman is, one might be
sending people into a building with the gunman,
or sending them outside where a gunman is
waiting. The shooters at the Jonesboro Middle
School massacre in Arkansas in 1998 planned to
create an alarm inside their school building and
get students and faculty to go outside where the
shooters were set up.
Cho, too, could have shot people in the open on
campus, after an alert went out, waiting for
them outside. Although he was armed with only
handguns, no one knew that at the time. The
Texas tower shooter sniped at people with a rifle
outdoors.
Impact of Lockdown or Closedown In this
event, the shooter was a member of the campus
community, an insider with a pass card to get
into his dorm, able to receive whatever message
was sent to the university community, and able
to go anywhere that students were allowed to
go. He would have received an alert, too.
It might be argued that the total toll would have
been less if the university had canceled classes
and announced it was closed for business imme-
diately after the first shooting; or if the earlier
alert message had been stronger and clearer.
Even with the messaging system that was in
place on April 16, many could have received
messages before they left for class by e-mail or
phone before 9 a.m., and the message probably
would have quickly spread mouth to mouth as
well. Even if it only partially reduced the uni-
versity population on campus, it might have
done some good. It is the panels judgment that,
all things considered, the toll could have been
reduced had these actions been taken. But none
of these measures would likely have averted a
mass shooting altogether. There is a possibility
that the additional measures would have dis-
suaded Cho from acting further, but he had al-
ready killed two people and sent a tape to NBC
that would arrive the following morning with all
but a confession. From what we know of his
mental state and commitment to action that
day, it was likely that he would have acted out
his fantasy somewhere on campus or outside it
that same day.
This was a single-shooter scenario; Columbine
High School had two shooters, and that scenario
was quite different. Emergency planners have to
anticipate various high-risk scenarios and how
to prepare for them. They must be aware that
what happens will rarely be just like the sce-
nario planned for. The right thing for one sce-
nario might be just the wrong thing to do for
another, such as whether to tell people to stay
inside buildings or get outside.
CONTINUING EVENTS
o continue the story of April 16, there was
not an event, a pause for 2 hours, and then
a second event. The notion that there was a 2-
hour gap as mentioned in some news stories and
by many who sent questions to the panel is a
T
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
85
misconception. There was continuous action and
deliberations from the first event until the sec-
ond, and they made a material difference in the
results of the second event.
Police Actions The VTPD and the other law
enforcement agencies involved did a profes-
sional job in pursuing the investigation of the
WAJ incident with the one large and unfortu-
nate exception of having conveyed the impres-
sion to the university administration that they
probably had a solid suspect who probably had
left the campus. These agencies did not know
that with certainty. A stronger patrol of the
campus and random checking of bags being car-
ried might have found Cho carrying guns. Cho,
however, was one of tens of thousands of stu-
dents on campus, did not stand out in appear-
ance, and carried his weapons in a backpack
like many other backpacks. The police had no
clues pointing to anyone other than the boy-
friend, and it would not have been reasonable to
expect them to be able to check what each per-
son on campus was carrying.
The VTPD and BPD mobilized their emergency
response teams after the first shooting. They did
not know what the followup would bring, but
they wanted to be ready for whatever occurred.
The VTPD had not investigated a homicide in
recent memory, and properly called on the
resources of the BPD, state police, and ulti-
mately ATF and FBI to assist in the investiga-
tion.
Boyfriend Questioning At 9:30 a.m., the
boyfriend of Emily Hilscher was stopped in his
pickup truck on a road. He was cooperative and
shocked to hear that his girlfriend had just been
killed. He passed a field test for the presence of
gunpowder residue. While he remained a person
of interest, it appeared unlikely that he was the
shooter, with the implication that the real
shooter was probably still at large. The police
passed this information to the university lead-
ership through the police captain who was in-
teracting with the university staff.
This negative finding on the boyfriend raised
the urgency of the situation, and the university
proceeded to send out more alerts of the chang-
ing situation, but by then it was too late.
Even after they realized he was not a likely sus-
pect and had been traumatized by the news of
his girlfriends death, the police agencies
involved in stopping and questioning Emily
Hilschers boyfriend did not treat him sympa-
thetically; he deserved better care.
Chos Next Actions After shooting the two
students in WAJ, Cho went back to his own
dormitory, arriving at 7:17 a.m. (based on the
record of his swipe card). He changed out of his
blood-stained clothing, which was later found in
his room. He accessed his university computer
account at 7:25 a.m. and proceeded to delete his
e-mails and wipe out his account. He then re-
moved the hard drive of his computer and later
disposed of it and his cell phone. Cho apparently
also had planned to dispose of his weapons after
using them in a different scenario because he
had filed down the serial numbers on the guns.
51

Mentally disturbed killers often make one plan
and then change it for some reason. The motiva-
tion may never be known for why he partially
obscured his identity and did not carry any
identification into Norris Hall, but then sent his
manifesto to a national news network with his
pictures.
Between 8:10 and 8:20 a.m., an Asian male
thought now to be Cho was seen at the Duck
Pond. (The pond has been searched unsuccess-
fully for the whereabouts of his phone and hard
drive, which are still missing.)
Before 9:00 a.m., Cho went to the Blacksburg
post office off campus, where he was recognized
by a professor who thought he looked frighten-
ing. At 9:01 a.m., he mailed a package to NBC
News in New York and a letter to the univer-
sitys English Department.
Diatribe The panel was allowed to view the
material Cho sent to NBC. The package was
signed A. Ishmael, similar to the Ax Ishmael

51
The ATF laboratory was able to raise the numbers and
identify the weapons collected after the shootings.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
86
name he had written on his arm in ink at the
time he committed suicide and also the name he
used to sign some e-mails. The significance of
this name remains to be explained, but it may
tie to his self-view as a member of the
oppressed.
Inside the package was a CD with a group of
about 20 videos of himself presenting his
extreme complaints against the world, two ram-
bling, single-spaced letters with much the same
information that were used as the scripts for the
videos, and pictures of himself with written cap-
tions. The pictures showed him wielding weap-
ons, showing his preparations for a mass mur-
der, and railing against society that had ill-
treated him. He seemed to be trying to look
powerful posing with weapons, the avenger for
the mistreated and downtrodden of the world,
and even its savior, in his words.
The videos and pictures in the package appear
to have been taken at various times in a motel,
a rented van, and possibly his dorm room over
the previous weeks. It is likely that he alone
took the photos; he can be seen adjusting the
camera.
His words to the camera were more than most
people had ever heard from him. He wanted his
motivation to be known, though it comes across
as largely incoherent, and it is unclear as to ex-
actly why he felt such strong animosity. His dia-
tribe is filled with biblical and literary refer-
ences and references to international figures,
but in a largely stream of consciousness man-
ner. He mentions no one he knew in the videos.
Rather, he portrays a grandiose fantasy of
becoming a significant figure through the mass
killing, not unlike American assassins of presi-
dents and public figures. The videos are a dra-
matic reading or performance of the writings
he enclosed. He read them several minutes at a
time, then reached up to turn off the camera,
changed the script he had mounted near the
camera, and continued again. They clearly were
not extemporaneous.
52
Intentionally or acciden-

52
NBC News in New York has the package Cho sent to
them and has released only a small amount of the material.
There is a balance between the public interest and the harm

tally, he even provided two takes of reading one
portion of his written diatribe.
After the mailings, Chos exact path is unknown
until he gets to Norris Hall.
MOTIVATION FOR FIRST KILLINGS?
o one knows why Cho committed the first
killings in the dormitory. He ran a great
risk of being seen and having any of a number of
things go wrong that could have thwarted his
larger plan. One line of speculation is that he
might have been practicing for the later killings,
since he had never shot anyone before (some
serial killers have been known to do this). He
may have thought he would create a diversion to
draw police away from where his main action
would later be, though in fact it worked the
opposite way. Many more police were on campus
than would have been there without the first
shootings, which allowed the response to the
second incident to be much faster and in greater
force. There is also a possibility that he consid-
ered attacking a woman as part of his revenge
he was known to have stalked at least three
women in the previous year and had complaints
registered against him, one from WAJ. Although
there is a small possibility he knew the victim,
no evidence of any connection has been found. In
fact, he did not really know any of his victims
that day, not faculty, roommates, or classmates.
None of the speculative theories as to motive
seem likely. The state and campus police have
not closed their cases yet, in part trying to
determine his motives.
KEY FINDINGS
enerally the VTPD and BPD officers re-
sponded to and carried out their investiga-
tive duties in a professional manner in

this material can do to families of victims, the potential for
giving incentive to future shooters, and the possibility of
hidden messages triggering actions of others. NBC spent
much time wrestling with what was the responsible thing to
do journalistically. It was a difficult set of decisions. They
did not
delay at all in getting the information package to the FBI
well before they released any of it.
N
G
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87
accordance with accepted police practices. How-
ever, the police conveyed the wrong impression
to the university Policy Group about the lead
they had and the likelihood that the suspect was
no longer on campus.
The police did not have the capability to use the
university alerting system to send a warning to
the students, staff, and faculty. That is, they
were not given the keyword to operate the alert-
ing system themselves, but rather they had to
request a message be sent from the Policy
Group or at least the associate vice president for
University Relations, who did have the key-
word. The police did have the authority to
request that a message be sent, but did not
request that be done. They gave the university
administration the information on the incident,
and left it to the Policy Group to handle the
messaging.
The university administration failed to notify
students and staff of a dangerous situation in a
timely manner. The first message sent by the
university to students could have been sent at
least an hour earlier and been more specific.
The university could have notified the Virginia
Tech community that two homicides of students
had occurred and that the shooter was unknown
and still at large. The administration could have
advised students and staff to safeguard them-
selves by staying in residences or other safe
places until further notice. They could have
advised those not en route to school to stay
home, though after 8 a.m. most employees
would have been en route to their campus jobs
and might not have received the messages in
time.
Despite the above findings, there does not seem
to be a plausible scenario of university response
to the double homicide that could have pre-
vented a tragedy of considerable magnitude on
April 16. Cho had started on a mission of fulfill-
ing a fantasy of revenge. He had mailed a pack-
age to NBC identifying himself and his rationale
and so was committed to act that same day. He
could not wait beyond the end of the day or the
first classes in the morning. There were many
areas to which he could have gone to cause
harm.
RECOMMENDATIONS
VII-1 In the preliminary stages of an inves-
tigation, the police should resist focusing
on a single theory and communicating that
to decision makers.
VII-2 All key facts should be included in an
alerting message, and it should be dissemi-
nated as quickly as possible, with explicit
information.
VII-3 Recipients of emergency messages
should be urged to inform others.
VII-4 Universities should have multiple
communication systems, including some
not dependent on high technology. Do not
assume that 21st century communications may
survive an attack or natural disaster or power
failure.
VII-5 Plans for canceling classes or closing
the campus should be included in the uni-
versitys emergency operations plan. It is not
certain that canceling classes and stopping work
would have decreased the number of casualties
at Virginia Tech on April 16, but those actions
may have done so. Lockdowns or cancellation of
classes should be considered on campuses where
it is feasible to do so rapidly.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87 - A
ADDITIONS AND CORRECTIONS
Chos Access to WAJ: p. 77, Clarification and Addition Cho had access to his mailbox in
the foyer of West Ambler Johnston residence hall, but only after 7:30 a.m. Cho did not have
key access to the rest of the residence hall. At about 6:45 a.m. he was seen loitering in the foyer
area, between the exterior and interior doors. He may have entered the foyer and then the in-
terior residential area when other students entered or exited, but no one remembered facilitat-
ing his entry.
Motive for Homicides: p. 77, Addition As of October 2009 no motive has been established
for the double homicide at WAJ. There have been speculations that it was a rehearsal and test
of nerve for the later actions, or a diversion, but the risk of being caught before committing the
mass murders was high. There was no mention in Chos writings or videotapes that suggested
a motive or link to the victims at WAJ. Cho had harassed a female student on the same floor as
Emily Hilscher, but neither Emilys roommate nor anyone else interviewed knew of any con-
nection between Emily and Cho.
Time of Shootings: p. 78, Addition The exact time of the double shooting is not known.
The Report stated not long after 7:15 a.m. Emily Hilscher had swiped her card upon entry to
WAJ at 7:02 a.m. and Cho swiped his entry card back at his dorm at 7:17 a.m. So Hilscher and
Clark were shot sometime between a few minutes after 7:02 and a few minutes before 7:17
a.m., depending on the path and speed of Hilscher as she went to her room, the interaction in
her room, and the path and speed of Cho as he returned to his room after the murders. The
first call to police was at 7:20 a.m., approximately 5 minutes after the shooting, after two stu-
dents had discussed whether to report the noise they heard.
Failure of Timely Notice to Emily Hilschers Family: p. 78, Addition No one from Vir-
ginia Tech or from the hospitals contacted the Hilscher family before she died to let them know
Emily had been shot and was severely wounded. The VTPD knew Emilys identity from infor-
mation provided by Heather Haugh, Emily Hilschers roommate, around 8:15 a.m. The Hil-
schers learned their daughter was a victim from the mother of Emilys boyfriend, Karl Thorn-
hill, and the Thornhills did not know where Emily had been taken. The Hilschers exerted every
effort to locate Emily but ran into problems with hospital personnel not wanting to disclose in-
formation over the phone. The family lived about a 3 hour drive from campus, but had the
family received a timely call and been told where Emily was being treated they would have had
a chance to at least place a call and talk to Emilys doctors and to her even if she could not re-
spond. Moreover, the Hilschers would not have had to go through the stress of not knowing
Emilys condition. Notification of family should have been an immediate priority and should
have been verified as having been performed by the Virginia Tech administrators, VTPD,
and/or Virginia State Police.
Additional Officials at WAJ: pp. 7879, Addition Dr. Spencer, Associate VP for Student
Affairs, arrived at WAJ at 7:55 a.m., and then called the VP for Student Affairs, Dr. Zenobia
Hikes with information on the events.
Emilys Roommate: p. 79, Addition The girlfriend of Emily Hilscher who was inter-
viewed by the police was Emilys roommate, Heather Haugh. The boyfriend of Emily referred to
in the text was Karl Thornhill. (The review panel chose to minimize use of student names to
focus on the lessons learned, and maintain privacy, but some victims families have asked that
these names be noted.)
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87 - B
Time of Roommate Interview: p. 79, Addition Emilys roommate Heather Haugh swiped
her card at WAJ at 8:14 a.m. and was then interviewed by the police. (She was interviewed in-
side the residence, so the interview time was after 8:14.) Police did not know about Emilys boy-
friend until that point. Immediately following the interview he became a person of interest.
The Policy Group did not know this fact until police updated them at 8:40 a.m. Until then the
Policy Group just knew there was a double shooting with both student victims critically
wounded, the shooter was unknown and at large, and that the initial police impression was
that it was probably a domestic issue.
Lockdown of WAJ: p. 79, Addition Police in effect locked down WAJ residence hall after
the shootings to process the crime scene and interview witnesses. Police were inside and out-
side the residence hall. No one was allowed to leave. The shooter was unknown and possibly
still present. Some time before 9:00 a.m. students in the dorm were allowed to exit and go to
class. Tragically, two of them were later killed during the mass shootings at Norris Hall. As
was normally the case, doors on all dormitories remained locked and required a residents scan
card to get in until 10:00 a.m.
Solution to Initial Homicides: p. 79, Clarification The Report states: If Cho had stopped
after the first two shootings, he might well have never been caught. That was the opinion of
VTPD Chief Flinchum reflecting on the paucity of evidence. There were shell casings, which
could help identify a gun once it was found, and bloody footprints, which could help identify a
shoe, but the gun and shoe had to be found and linked to a suspect. As a side note, at least
three states at the time, including Maryland and New York, required gun dealers to test-fire
each gun sold and send the results to the state, which maintained a registry and database of
this information. The gun purchaser could be identified from a shell casing found at a crime
scene. California went further, and required guns to have a chip inserted that marked each
casing with an identification number by which a gun purchaser could be rapidly identified. In
those states it is likely that the registered owner of the gun used in the shooting would have
been identified even if no other evidence were found.
Victim Still Alive: p. 79, Correction When the Policy Group was first informed about the
shootings, Emily Hilscher was still alive. The Report should not have referred to both victims
as homicides at that point in time. Emily survived for three hours while she was treated at two
hospitals.
Chief Flinchum Calls to BPD and Executive Vice President: p. 80, Clarification The Report
stated Chief Flinchum was notified about the shootings at 7:40 a.m. and then contacted
Blacksburg PD. The latter occurred at 7:51 a.m. He also tried to reach the Office of the Execu-
tive Vice President but did not get through until 7:57 a.m.
Delayed Alert: pp. 80-81, Correction and Addition President Steger first spoke directly
with Virginia Tech Police Chief Flinchum at 8:11 a.m., and then convened the Policy Group,
which met at 8:25 am. According to a police briefing for victims families, Chief Flinchum told
President Steger that two students were critically wounded, that no weapon was found, that
there were bloody footprints, and that the incident seemed to be domestic in nature. Chief
Flinchum did not offer a recommendation about an alert or closing the campus at that time nor
was he asked his opinion about doing so. Essentially, the police focused on the investigation
and hunt for the killer, and the Policy Group was left to handle the alert.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87 - C
The Review Panel had been told that the Policy Group was informed early on that there was a
person of interest. However, the first calls to the Policy Group and President could not have
mentioned a person of interest because it was not until at least a few minutes after the 8:14
A.M arrival of Emily Hilschers roommate at WAJ that the police learned of Emilys boyfriend
and that he owned a gun.
Under the provisions of Virginia Techs policy document called Campus Safety: A Shared Re-
sponsibility, the VTPD is given the responsibility and authority to send an emergency alert.
That document, formulated as part of Virginia Techs compliance with the Clery Act, required
issuing a timely warning. It stated in pertinent part:
i. (Page 1) Virginia Tech has designed policies and regulations in order to create a safer
and more harmonious environment for the members of its community. All campus com-
munity members and visitors of the university are required to obey these regulations.
These policies not only reflect the universitys high standards of conduct, but also local,
state and federal laws. Observed and enforced, they create a high degree of safety for the
university community.
ii. (Page 6) At time it may be necessary for timely warnings to be issued to the university
community. If a crime(s) occur [sic] and notification is necessary to warn the University of
a potential[sic] dangerous situation then the Virginia Tech Police Department should be
notified. The police department will then prepare a release and the information will be
disseminated to all students, faculty and staff and to the local community.
However, Virginia Techs Emergency Management Plan also contained formal emergency alert
procedures and these assigned authority for releasing a warning to the Policy Group only. The
two documents and policies were inconsistent. The one that VTPD and the Policy Group fol-
lowed on April 16
th
was the Emergency Management Plan because that Plan was the one with
which they were familiar and historically had used as their basis of operations. Under the
Emergency Management Plan, the VTPD could request or develop, but not send, an alert be-
cause they did not have the computer code needed to send out a warning. Only two Virginia
Tech officials had the code, and the police chief was not one of them. The code was needed to
ensure that any message was authorized, and was not a false alarm which had occurred pre-
viously in some messages to the local media.
Pre-Alert Actions to Protect: p. 83, Addition The Report stated that few on campus acted
on the first warning message sent, and that still appears to be generally correct. However,
there were a growing number of actions taken even before the first official warning message
from Virginia Tech was sent, as word of the shootings spread by word of mouth and media and
other means. Some people who had information about the double shooting acted to protect their
safety and the safety of others for whom they had responsibility, even before receiving an offi-
cial message. For example, the Center for Professional and Continuing Education, and the
Veterinary College, locked down on their own accord. The VT Governmental Affairs Director
ordered the Presidents office to be locked. VTPD cancelled bank deposit pickups and trash col-
lection. The Blacksburg schools also made the decision to lock down.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87 - D
Field Test for Gunpowder Residue: p. 86, Correction The Report said that Emily Hil-
schers boyfriend had passed a gunpowder residue test when he was stopped on the road. In
fact, Thornhill was given the Primer Residue Test, but unlike some other gunpowder tests this
one does not give a preliminary result in the field. Rather, the sample requires analysis in a
crime lab. The sample was packaged for submission to a lab but the analysis was never done as
events overtook the need to do so.
The Report also said that information on the results of the gunpowder test was passed on to
the Policy Group. Since no analysis was performed no results could have been provided to the
Policy Group. The Policy Group was informed of the roadside stop and test. Thus at no time on
April 16 did the Policy Group have information that the person of interest was cleared for the
initial double shooting. Police doubted Thornhill was a suspect after interviewing him, but he
was kept as a person of interest until the next day.
When stopped by the police, Thornhill was only told that his girlfriend Emily Hilscher was
shot, not that she was severely wounded. He did not know whether she was in a hospital or
anything else about her situation. Police left him immediately upon receiving word about the
Norris Hall attack, and Thornhill continued searching for Emily.
Search of Thornhill Apartment: p. 86, Correction and Addition In the evening of the
shooting, a police ERT (SWAT team) entered the residence of Karl Thornhill, Emily Hilschers
boyfriend. They handcuffed him and put him on the floor while they searched his apartment.
They also handcuffed and put on the floor his family members who had arrived to console him.
The police had a search warrant, but did not present it until they were leaving. Thornhill and
his family were cooperative but felt they had been treated with a heavy hand unnecessarily,
especially since police had released Thornhill after the traffic stop that morning, and did not
bring him in for questioning later in the day. They did not realize he was still considered a sus-
pect. However, it should be noted that the link between the double shooting and the mass
shooting had not yet been proven, and police knew Thornhill had a gun, so they were exercising
caution in the interest of everyones safety, even though unpleasant and traumatic for the
Thornhill family.
OTHER COMMENTS
Page 81 of the Report discusses reasons why Virginia Tech delayed sending an alert. One fam-
ily member commented that police informed families in a 2009 briefing that another reason for
not immediately informing the campus was to avoid making the police work and investigation
more difficult. Police Chief Flinchum has denied making this remark and it may or may not
have been made by others or correctly understood. Nevertheless, there are indeed tradeoffs be-
tween informing a community of what has happened so they have context in which to take ac-
tions for their own safety, and possibly informing the perpetrator(s) of police knowledge and
action, potentially making the investigation more difficult. The consensus of the Review Panel
and many others in hindsight was that early warning should have received the higher priority
in this situation. With the events at Virginia Tech as an example, early warning with the
known facts now is the widely adopted practice in numerous colleges and universities as well
as other venues.
CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON
87 - E
Page 87 of the Report contains a discussion of what might have happened had there been ear-
lier warning sent to Virginia Tech students and staff about a shooter on the loose. The Report
spoke of Cho fulfilling a fantasy of revenge which he had articulated in the videos he sent to
NBC and that it was likely he would have found some variation on his plan, since he had al-
ready essentially committed himself by mailing the videotaped message at 9:00 a.m. and was
probably of a mind to complete his mission. The question was asked by a victim family mem-
ber: what would have resulted if the warning went out prior to 9:00 a.m., and Cho heard about
or saw evidence of a manhunt and preventive measures such as additional police patrols, build-
ings being locked down, etc. before he sent out the videos? Might he have not sent the tape and
aborted his mission?
There are many what if questions that can be raised, and no one knows the answers for cer-
tain. The forensic psychologist on the Review Panel thought that most likely Cho was commit-
ted to his mission: he had purchased and trained with his weapons, had obtained chains for the
doors and rehearsed using them, and had thought out the scenario. When Cho returned to his
dorm room, he erased his hard drive and deleted his Virginia Tech account, a sign he was start-
ing a departure process. If not implementing his scheme as originally planned, he could have
staged a variation that day in a residence hall, dining hall, or out in the open, or waited an-
other day.
Another family member asked why the Virginia Tech Emergency Plan was not updated after
the Morva incident the previous year, in which the gunman was (incorrectly) thought to be on
campus. Though the plan was not revised, and no annex written specifically for handling a
shooting incident or a shooter loose on campus, some major changes in preparedness were in
process. The whole emergency alerting system was being upgraded significantly at the time of
the April 16, 2007 incidents. The police departments in the region practiced how to handle a
shooting incident. The VT Rescue Squad practiced handling mass casualty incidents. These po-
lice and EMS preparations undoubtedly saved lives on April 16.
A third question was why Virginia Tech did not conduct exercises for sending out an alert. Vir-
ginia Tech sent actual alerts for weather emergencies and other events from time to time, and
was testing parts of the new emergency response system as they came on-line. Once the system
was completed, it was tested again.

89
Chapter VIII.
MASS MURDER AT NORRIS HALL
any police were on campus in the 2 hours
following the first incident, most at West
Ambler Johnston residence hall but others at a
command center established for the first inci-
dent. Two emergency response teams (ERTs)
were positioned at the Blacksburg Police
Department (BPD) headquarters, and a police
captain was with the Virginia Tech Policy Group
acting as liaison.
Cho left the post office about 9:01 a.m. (the time
on his mailing receipt). He proceeded to Norris
Hall wearing a backpack with his killing tools.
He carried two handguns, almost 400 rounds of
ammunition most of which were in rapid loading
magazines, a knife, heavy chains, and a hammer.
He wore a light coat to cover his shooting vest.
He was not noticed as being a threat or peculiar
enough for anyone to report him before the
shooting started.
In Norris Hall, Cho chained shut the pair of
doors at each of the three main entrances used
by students. Figure 7 shows one such entrance.
The chaining had the dual effect of delaying any-
one from interrupting his plan and keeping vic-
tims from escaping. After the Norris Hall inci-
dent, it was reported to police that an Asian male
wearing a hooded garment was seen in the vicin-
ity of a chained door at Norris Hall 2 days before
the shootings, and it may well have been Cho
practicing. Cho may have been influenced by the
two Columbine High School killers, whom he
mentioned in his ranting document sent to NBC
News and previously in his middle school writ-
ings. He referred to them by their first names
and clearly was familiar with how they had car-
ried out their scheme.
On the morning of April 16, Cho put a note on
the inside of one set of chained doors warning
that a bomb would go off if anyone tried to
remove the chains. The note was seen by a fac-
ulty member, who carried it to the Engineering
Figure 7. One of the Main Entrances to Norris Hall
School deans office on the third floor. This was
contrary to university instructions to immedi-
ately call the police when a bomb threat is found.
A person in the deans office was about to call the
police about the bomb threat when the shooting
started. A handwriting comparison revealed that
Cho wrote this note, but that he had not written
bomb threat notes found over the previous weeks
in three other buildings. Those threats, which led
to the evacuation of the three buildings, proved
to be false. That may have contributed to the Cho
note not being taken seriously, even though
found on a chained door.
The usual VTPD protocol for a bomb threat that
is potentially real is to send officers to the threat-
ened building and evacuate it. Had the Cho bomb
threat note been promptly reported prior to the
M
CHAPTER VIII. MASS MURDER AT NORRIS HALL
90
start of the shooting, the police might have ar-
rived at the building sooner than they did.
A female student trying to get into Norris Hall
shortly before the shooting started found the
entrance chained. She climbed through a window
to get where she was going on the first floor. She
did not report the chains, assuming they had
something to do with ongoing construction.
Other students leaving early from an accounting
exam on the third floor also saw the doors
chained before the shooting started, but no one
called the police or reported it to the university.
Prior to starting the shootings, Cho walked
around in the hallway on the second floor poking
his head into a few classrooms, some more than
once, according to interviews by the police and
panel. This struck some who saw him as odd
because it was late in the semester for a student
to be lost. But no one raised an alarm. Figure 8
shows the hallway in Norris Hall.
Figure 8. Hallway in Norris Hall
THE SHOOTINGS
he occupants of the first classroom that Cho
attacked had little chance to call for help or
take cover. After peering into several classrooms,
Cho walked into the Advanced Hydrology engi-
neering class of Professor G. V. Loganathan in
room 206, shot and killed the instructor, and
continued shooting, saying not a word. In fact, he
never uttered a sound during his entire shooting
spreeno invectives, no rationale, no comments,
nothing. Even during this extreme situation at
the end of his life, he did not speak to anyone. Of
13 students present in the classroom, 9 were
killed and 2 injured by shooting, and only 2 sur-
vived unharmed. No one in room 206 was able to
call the police.
Occupants of neighboring classrooms heard the
gunshots but did not immediately recognize
them as gunfire. One student went into the hall-
way to investigate, saw what was happening,
and returned to alert the class.
First Alarm to 9-1-1 Cho started shooting
at about 9:40 a.m. It took about a minute for stu-
dents and faculty in room 211, a French class, to
recognize that the sounds they heard in the
nearby room were gunshots. Then the instructor,
Jocelyne Couture-Nowak, asked student Colin
Goddard to call 9-l-l.
Cell phone 9-1-1 calls are routed according to
which tower receives them. Goddards call was
routed to the Blacksburg police. Another call by
cell phone from room 211 was routed first to the
Montgomery County sheriff. The call-taker at the
BPD received the call at 9:41 a.m. and was not
familiar with campus building names. But it took
less than a minute to sort out that the call was
coming from Virginia Tech and it was then
transferred to the Virginia Tech Police Depart-
ment (VTPD).
At 9:42 a.m., the first call reached the Virginia
Tech police that there was shooting in Norris
Hall. Other calls later came from other class-
rooms and offices in Norris Hall and from other
buildings.
Students and faculty in other nearby rooms also
heard the first shots, but no one immediately
realized what they were. Some thought they
were construction noises. Others thought they
could be the popping sounds sometimes heard
from chemistry lab experiments on the first floor.
One professor told his class to continue with the
lesson after some raised questions about the
noise. When the noise did not stop, some people
went into the hallway to investigate. One stu-
dent from an engineering class was shot when he
T
CHAPTER VIII. MASS MURDER AT NORRIS HALL
91
entered the hallway. At that point, terror set in
among the persons in the classrooms who real-
ized that what they were hearing was gunfire.
Continued Shooting This section portrays
the sense of the key action rather than trace the
exact path of Cho. It is based on police presenta-
tions to the panel, police news releases, and in-
terviews conducted by the panel.
After killing Professor Loganathan and several
students in room 206, Cho went across the hall
to room 207, a German class taught by Christo-
pher James Bishop. Cho shot Professor Bishop
and several students near the door. He then
started down the aisle shooting others. Four stu-
dents and Bishop ultimately died in this room,
with another six wounded by gunshot. One stu-
dent tried to wrench free the podium that was
fastened securely to the floor in order to build a
barricade at the door. She was unsuccessful and
injured herself in the process.
As Goddard called 9-1-1 from classroom 211,
Couture-Nowaks class tried to use the instruc-
tors table to barricade the door, but Cho pushed
his way in, shot the professor, and walked down
the aisle shooting students. Cho did not say any-
thing. Goddard was among the first to be shot.
Another student, Emily Haas, picked up
Goddards cell phone after he was shot. She
stayed on the line for the rest of the shooting
period. She was slightly wounded twice in the
head by bullets, spoke quietly as long as she
could to the dispatcher, heard that the police
were responding, closed her eyes, and played
dead. She said she did not open her eyes again
for over 10 minutes until the police arrived. Dur-
ing her ordeal, she was concerned that the
shooter would hear the 9-1-1 dispatch operator
over the cell phone. But by keeping the line open
she helped keep police apprised of the situation.
She kept the phone hidden by her head and hair
so she could appear dead but not disconnect.
Although the dispatcher at times asked her ques-
tions and at other times told her to keep quiet,
she spoke only when Cho was out of the room,
which she could tell by the proximity of the
shots.
Students in room 205 attending a class in scien-
tific computing heard Chos gunshots and barri-
caded the door to prevent his entry, mainly with
their bodies kept low, holding the door with their
feet. Cho never did succeed in getting into this
room though he pushed and fired through the
door several times. No one was injured by gun-
shot in this room.
Back in room 207, the German class, two un-
injured students and two injured students
rushed to the door to hold it shut with their feet
and hands before Cho returned, keeping their
bodies low and away from the center of the door.
Within 2 minutes, Cho returned and beat on the
door. He opened it an inch and fired about five
shots around the door handle, then gave up try-
ing to reenter and left.
Cho returned to room 211, the French class, and
went around the room, up one aisle and down
another, shooting students again. Cho shot
Goddard two more times. Goddard lay still and
played dead. This classroom received the most
visits by Cho, who ultimately killed 11 students
and the instructor, and wounded another 6, the
entire class. A janitor saw Cho reloading his gun
in the hall on the second floor and fled down-
stairs.
Cho tried to enter the classroom of engineering
professor Liviu Librescu (room 204), who was
teaching solid mechanics. Librescu braced his
body against the door and yelled for students to
head for the window. Students pushed out the
screens and jumped or dropped onto bushes or
the grassy ground below the window. Ten of the
16 students escaped this way. The next two stu-
dents trying to leave through the window were
shot. Librescu was fatally shot through the door
trying to hold it closed while his students
escaped. A total of four students were shot in
this class, one fatally.
Cho returned to most of the classrooms more
than once to continue shooting. He methodically
fired from inside the doorways of the classrooms,
and sometimes walked around inside them. It
was very close range. Students had little place to
CHAPTER VIII. MASS MURDER AT NORRIS HALL
92
hide other than behind the desks. By taking a
few paces inside he could shoot almost anyone in
the classroom who was not behind a piece of
overturned furniture. The classrooms were all
roughly square, with no obstructions. Figure 9
shows the interior of a typical classroom, seen
from the corner furthest from the door. Table 1
shows the dimensions of the rooms with the
shootings.
Figure 9: Interior of Typical Classroom

Table 1. Dimensions of the Classrooms Attacked
Room # Dimensions
204 28 x 25
205 24 x 25
206 22 x 25
207 24 x 25
211 22 x 25
The rooms were furnished with lightweight
deskchair combinations, single units combining
both functions. Each instructor had a table desk
and a podium, the latter bolted to the floor. The
doors were not lockable from the inside. Unlike
many lower grade schools and typical of most
colleges, the instructors had no university-
furnished messaging system for receiving or
sending an alarm. Emergency communications
from classrooms were limited to any phone or
electronic devices carried by students or instruc-
tors. The offices had standard telephones, but
they were on the third floor.

The massacre continued for 9 minutes after the
first 9-1-1 call was received by the VTPD, and
about 1012 minutes in total, including a minute
for processing and transferring the call to VTPD,
and the time to comprehend that shots were
being fired and to make the call. From the first
call, shots can be heard continuously on the dis-
patch tapes, until they stopped with the suicide
shot.
Within that period, Cho murdered 25 students
and 5 faculty of Virginia Tech at Norris Hall.
Another 17 were shot and survived, and 6 were
injured when they jumped from classroom win-
dows to escape.
Cho expended at least 174 bullets from two
semiautomatic guns, his 9mm Glock and .22 cali-
ber Walther, firing often at point-blank range.
The police found 17 empty magazines, each
capable of holding 1015 bullets. Ammunition
recovered included 203 live cartridges,122 for the
Glock and 81 for the Walther. The unexpended
ammunition included two loaded 9mm maga-
zines with 15 cartridges each and many loose
bullets.
Cho committed suicide by shooting himself in the
head, probably because he saw and heard the
police closing in on him. With over 200 rounds
left, more than half his ammunition, he almost
surely would have continued to kill more of the
wounded as he had been doing, and possibly
others in the building had not the police arrived
so quickly. Terrible as it was, the toll could have
been even higher.
DEFENSIVE ACTIONS
ccording to survivors, the first reaction of
the students and faculty was disbelief, fol-
lowed rapidly by many sensible and often heroic
actions. One affirmative judgment in reflecting
on this event is that virtually no one acted irra-
tionally. People chose what they thought was the
best option for their survival or to protect others,
and many tried to prevent the shooter from gain-
ing access to their room. Unfortunately, a
shooter operating at point-blank range does not
offer many options.
A
CHAPTER VIII. MASS MURDER AT NORRIS HALL
93
Escaping Professor Librescus class was the
only one where students escaped by jumping
from windows. This classroom's windows face a
grassy area. (Figure 10 is the view from outside
and Figure 11 shows the structure of the win-
dows. The view from inside looking out is shown
in Figure 12.)
Figure 10. Norris Hall Classroom
Windows, Grassy Side

Figure 11. Typical Set of Windows in Norris Hall

Figure 12. To Escape, They Had to
Climb Over the Low Window
The window sills are 19 feet high from the
ground, two stories up. In order to escape
through the window, the first jumper, a male
student, had to take down a screen, swing the
upper window outward, climb over the lower por-
tion of the window that opened into the class-
room, and then jump. He tried to land on the
bushes. Following his example, most of the rest
of the class formed groups behind three windows
and started jumping. All who jumped survived,
some with broken bones, some uninjured except
for scratches or bruises. Some survivors did the
optimum window escape, lowering themselves
from the window sill to drop to the ground, re-
ducing the fall by their body length.
The other classes faced out onto concrete walks
or yards, and jumping either did not seem a good
idea or perhaps did not even enter their minds.
No one attempted to jump from any other class-
room.
CHAPTER VIII. MASS MURDER AT NORRIS HALL
94
Some attempts were made by a few students to
escape out of the classroom and down the hall in
the earliest stage of the incident. But after some
people were shot in the hall, no one else tried
that route.
Attempting to Barricade In three of the
four classrooms that Cho invaded and one more
that resisted invasion, the instructor and stu-
dents attempted to barricade the door against
Cho entering either on his first attempt or on a
later try. They tried to use the few things avail-
able the teachers table, the deskchair combi-
nations, and their bodies. Some attempts to bar-
ricade succeeded and others did not. Cho pushed
his way in or shot through some doors that were
being barricaded. In the German class, two
wounded students and two non-wounded stu-
dents managed to hold the door closed against
the return entry by Cho. They succeeded in stay-
ing out of the line of fire through the door. Two
other rooms did the same. In one, Cho never did
get in. At least one effort was made to use the
podium, but it failed (it was bolted to the floor).
Cho was not a strong personhis autopsy noted
weak musculatureand these brave students
and faculty helped reduce the toll.
Playing Dead Several students, some of
whom were injured and others not, successfully
played dead amid the carnage around them, and
survived. Generally, they fell to the ground as
shots were fired, and tried not to move, hoping
Cho would not notice them. Cho had systemati-
cally shot several of his victims a second time
when he saw them still alive on revisiting some
of the rooms, so the survivors tried to hold still
and keep quiet. This worked for at least some
students.
POLICE RESPONSE
ithin 3 minutes of the Virginia Tech police
receiving the 9-1-1 call, two officers arrived
outside of Norris Hall by squad car. They were
Virginia Tech officer H. Dean Lucas and Blacks-
burg Sgt. Anthony Wilson. A few seconds later,
three more officers arrived by car: Blacksburg
Police Department officers John Glass, Scott
Craig, and Brian Roe. More continued to arrive
throughout the incident.
By professional standards, this was an extra-
ordinarily fast police response. The officers had
been near WAJ as part of the investigation and
security following the first incident, so they were
able to respond much faster than they otherwise
would have. The two police forces trusted each
other, had trained together, and did not have to
take time sorting out who would go from which
organization in which car. They just went
together as fast as they could.
The five officers immediately proceeded to
implement their training for dealing with an
active shooter. The policy is to go to the gunfire
as fast as possible, not in a careless headlong
rush, but in a speedy but careful advance. The
first arriving officers had to pause several sec-
onds after exiting their cars to see where the
gunfire was coming from, especially whether it
was being directed toward them. They quickly
figured out that the firing was inside the build-
ing, not coming from the windows to the outside.
Because Cho was using two different caliber
weapons whose sounds are different, the
assumption had to be made that there was more
than one shooter.
The officers tried the nearest entrance to Norris
Hall, found it chained, quickly proceeded to a
second and then a third entrance, both also
chained. Attempts to shoot off the padlocks or
chains failed. They then moved rapidly to a
fourth entrancea maintenance shop door that
was locked but not chained. They shot open the
conventional key lock with a shotgun. Five police
officers entered and rapidly moved up the stairs
toward the gunfire, not knowing who or how
many gunmen were shooting.
The first team of five officers to enter Norris Hall
after the door lock was shot were:
VT Officer H. Dean Lucas (patrol)
Blacksburg Officer Greg Evans (patrol)
Blacksburg Officer Scott Craig (SWAT)
Blacksburg Officer Brian Roe (SWAT)
Blacksburg Officer Johnny Self (patrol)
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CHAPTER VIII. MASS MURDER AT NORRIS HALL
95
They were followed seconds later by a second
team of seven officers:
VT Lt. Curtis Cook (SWAT)
VT Sgt Tom Gallemore (SWAT)
VT Sgt Sean Smith (SWAT)
VT Officer Larry Wooddell (SWAT)
VT Officer Keith Weaver (patrol)
VT Officer Daniel Hardy (SWAT)
Blacksburg Officer Jeff Robinson (SWAT)
Both teams had members from more than one
police department. The first police team got to
the second floor hallway leading to the class-
rooms as the shooting stopped. The second police
team that entered went upstairs to the opposite
end of the shooting hallway on the second floor.
They saw the first team at the opposite end of
the hall and held in place to avoid a crossfire
should the shooter emerge from a room. They
then went to clear the third floor.
The first team of officers arriving on the second
floor found it eerily quiet. They approached cau-
tiously in the direction from which the shots
were fired. They had to clear each classroom and
office as they passed it lest they walk past the
shooter or shooters and get fired upon from the
rear. They saw casualties in the hallway and a
scene of mass carnage in the classrooms, with
many still alive. Although the shooter was even-
tually identified, he was not immediately appar-
ent, and they were not certain whether other
shooters lurked. This seemed a distinct possibil-
ity. As one police sergeant later reflected: How
could one person do all this damage alone with
handguns?
Some people have questioned why the police
could not force entry into the building more
quickly. First, most police units do not carry bolt
cutters or other entry devices; such tools would
rarely be used by squad car officers. They usually
are carried only in the vans of special police
units. Second, the windows on the first floor are
very narrow, as on all floors of Norris Hall. A
thin student could climb through them; a heavily
armed officer wearing bulletproof vest could not.
Knocking down a door with a vehicle was not
possible given the design and site of the building.
The auditorium connecting Norris Hall with
Holden Hall and shared by both could have been
used as an entry path, but it would have taken
longer to get in by first running into Holden
Hall, going through it, and then up the stairs to
Norris Hall. The police ERT had the capability of
receiving plans of the buildings by radio from the
fire department, but that would have taken too
long and was not needed in the event.
During the shooting, a student took pictures
from his cell phone that were soon broadcast on
television. They showed many police outside of
Norris Hall behind trees and cars, some with
guns drawn, not moving toward the gunfire.
Most of them were part of a perimeter estab-
lished around the building after the first officers
on the scene made entry. The police were follow-
ing standard procedure to surround the building
in case the shooter or shooters emerged firing or
trying to escape. What was not apparent was
that the first officers on the scene already were
inside.
Once the shooting stopped, the first police on the
scene switched modes and became a rescue team.
Four officers carried out a victim using a dia-
mond formation, two actually doing the carrying
and two escorting with guns drawn. At this
point, it still was not known whether there was a
second shooter. The police carried several victims
who were still alive to the lawn outside the build-
ing, where they were turned over to a police-
driven SUV that took the first victims to emer-
gency medical treatment. (The emergency medi-
cal response is discussed in Chapter IX.)
A formal incident commander and emergency
operations center was not set up until after the
shooting was over mainly because events
unfolded very rapidly. A more formal process was
used for the follow-up investigation.
UNIVERSITY MESSAGES
hen university officials were apprised of
the Norris Hall shootings, they were horri-
fied. Vice Provost Ford explained the events as
follows (continuing his statement presented to
the panel from the previous chapter):
W
CHAPTER VIII. MASS MURDER AT NORRIS HALL
96
At approximately 9:45 a.m., the Policy Group
received word from the Virginia Tech police
of a shooting in Norris Hall. Within five
minutes, a notification was issued by the
Policy Group and transmitted to the univer-
sity community which read:
A gunman is loose on campus. Stay in
buildings until further notice. Stay away
from all windows.
Also activated was the campus emergency
alert system. The voice message capability of
that system was used to convey an emer-
gency message throughout the campus.
Given the factual information available to
the Policy Group, the reasonable action was
to ask people to stay in place. The Policy
Group did not have evidence to ensure that a
gunman was or was not on the loose, so every
precaution had to be taken. The Virginia
Tech campus contains 153 major buildings,
53
19 miles of public roads, is located on 2,600
acres of land, and as many as 35,000 indi-
viduals might be found on its grounds at any
one time on a typical day. Virginia Tech is
very much like a small city. One does not en-
tirely close down a small city or a university
campus.
Additionally, the Policy Group considered
that the university schedule has a class
change between 9:55 a.m. and 10:10 a.m. on
a MWF schedule. To ensure some sense of
safety in an open campus environment, the
Policy Group decided that keeping people
inside existing buildings if they were on
campus and away from campus if they had
not yet arrived was the right decision. Again,
we made the best decision we could based on
the information available. So at approxi-
mately 10:15 a.m. another message was
transmitted which read:
Virginia Tech has cancelled all classes.
Those on campus are asked to remain where
they are, lock their doors, and stay away
from windows. Persons off campus are asked
not to come to campus.
At approximately 10:50 a.m., Virginia Tech
Police Chief Flinchum and Blacksburg Police
Chief Crannis arrived to inform the Policy

53
From another university source, we identified 131 major
buildings and several more under construction. In any event,
it is a large number of structures.
Group about what they had witnessed in the
aftermath of the shootings in Norris Hall.
Chief Flinchum reported that the scene was
bad; very bad. Virginia state police was han-
dling the crime scene. Police had one shooter
in custody and there was no evidence at the
time to confirm or negate a second shooter,
nor was there evidence at the time to link the
shootings in West Ambler Johnston to those
in Norris Hall. The police informed the Policy
Group that these initial observations were
ongoing investigations.
Based upon this information and acting upon
the advice of the police, the Policy Group
immediately issued a fourth transmittal
which read:
In addition to an earlier shooting today in
West Ambler Johnston, there has been a
multiple shooting with multiple victims in
Norris Hall. Police and EMS are on the
scene. Police have one shooter in custody and
as part of routine police procedure, they con-
tinue to search for a second shooter.
All people in university buildings are
required to stay inside until further notice.
All entrances to campus are closed.
Information about the Norris Hall shootings
continued to come to the Policy Group from
the scene. At approximately 11:30 [a.m.], the
Policy Group issued a planned facultystaff
evacuation via the Virginia Tech web site
which read:
Faculty and staff located on the Burruss
Hall side of the drill field are asked to leave
their office and go home immediately. Fac-
ulty and staff located on the War Memorial/
Eggleston Hall side of the drill field are
asked to leave their offices and go home at
12:30 p.m.
At approximately 12:15 p.m., the Policy
Group released yet another communication
via the Virginia Tech web site which further
informed people as follows:
Virginia Tech has closed today Monday,
April 16, 2007. On Tuesday, April 17,
classes will be cancelled. The university will
remain open for administrative operations.
There will be an additional university state-
ment presented today at noon.
4 5
CHAPTER VIII. MASS MURDER AT NORRIS HALL
97
All students, faculty and staff are required
to stay where they are until police execute a
planned evacuation. A phased closing will
be in effect today; further information will be
forthcoming as soon as police secure the
campus.
Tomorrow there will be a university con-
vocation/ceremony at noon at Cassell Coli-
seum. The Inn at Virginia Tech has been
designated as the site for parents to gather
and obtain information.
A press conference was held shortly after
noon on April 16, 2007, and President
Charles W. Steger issued a statement citing
A tragedy of monumental proportions.
Copies of that statement are available on
request.
The Policy Group continued to meet and
strategically plan for the events to follow. A
campus update on the shootings was issued
at another press conference at approxi-
mately 5:00 p.m.
It should be noted that the above messages were
sent after the full gravity of what happened at
Norris Hall had been made known to the Policy
Group. They were too late to be of much value for
security. The messages still were less than full
disclosure of the situation. There may well have
been a second shooter, and the university com-
munity should have been told to be on the look-
out for one, not that the continued search was
just routine police procedure. When almost 50
people are shot, what follows is hardly routine
police procedure. The university appears to have
tempered its messages to avoid panic and reduce
the shock and fright to the campus family. But a
more straightforward description was needed.
The messages still did not get across the enor-
mity of the event and the loss of life. By that
time, rumors were rife. The events were highly
disturbing and there was no way to sugarcoat
them. Straight facts were needed.
OTHER ACTIONS ON THE SECOND
AND THIRD FLOORS
hile the shootings were taking place in class-
rooms on the second floor of Norris Hall, people
on the other floors and in offices on the second
floor tried to flee or take refugewith one
exception. Professor Kevin Granata from the
third floor guided his students to safety in a
small room, locked the room and went to investi-
gate the gunfire on the second floor. He was shot
and killed. People who did take refuge in locked
rooms were badly frightened by gunfire and the
general commotion, but all of them survived.
In the first minutes after they arrived, the police
could not be sure that all of the shooters were
dead. The police had to be careful in clearing all
rooms to ensure that there was not a second
shooter mixed in with the others. In fact, perpe-
trators can often blend with their victims,
Groups of police went through the building clear-
ing each office, lab, classroom, and closet. When
they encountered a group of people hiding in a
bathroom or locked office, they had to be wary.
The result was that many people were badly
frightened a second time by the police clearing
actions. Some were sent downstairs accompanied
by officers and others were left to make their
own way out. Although quite a few officers were
in the building at this time, they still did not
have sufficient members to clear all areas and
simultaneously escort out every survivor. It also
appears that there was inadequate communica-
tion between the police who were clearing the
building and those outside guarding the exits.
For example, one group of professors and staff
was hiding behind the locked doors of the Engi-
neering Department offices on the third floor.
When they were cleared by police to evacuate,
they were directed down a staircase toward an
exit where they found a chained door with police
outside pointing guns at them. One of them
remembered that there was an exit through the
auditorium to Holden Hall and they left that
way.
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CHAPTER VIII. MASS MURDER AT NORRIS HALL
98
The group of students from Professor Granatas
third-floor class that hid in a small locked office
were frightened by officers approaching with
guns at the ready, but then were escorted safely
out of the building.
The police had their priorities straight. Although
many survivors were frightened, the police
understandably were focused on clearing the
building safely and quickly. Had there been a
second shooter not found quickly, the police
would have wasted manpower escorting people
out instead of searching for and neutralizing the
shooter.
ACTION ON THE FIRST FLOOR
ccording to VTPD Chief Flinchum:
When officers entered Norris Hall, two
stayed on the first floor to secure it. One
officer said one or two people came out of
rooms and were evacuated. Officers on the
second floor took survivors down to the first
floor on the Drillfield side of Norris, but
they had to shoot the lock on the chained
door to get out. When they did this, other
officers entered Norris and began initial
clearing of the first floor while the other
teams were clearing the third and second
floors. The first floor was cleared again by
SWAT after the actions on the second floor
were completed.
This all was appropriate, thorough police
procedure.
THE TOLL
n about 10 minutes, one shooter armed with
handguns shot 47 students and faculty, of
whom 30 died. The shooters self-inflicted wound
made the toll 48.
Of the seven faculty conducting classes, five were
fatally shot. Three were standing in the front of
their classrooms when the gunman walked in.
One was shot barricading the door, and one shot
while investigating the sounds after getting his
class to safety on the third floor. They were brave
and vulnerable.
Based on university records, 148 students were
on the rolls of classes held at 9:05 a.m. in Norris
Hall on April 16. At least 31 and possibly a few
more missed classes or had classes cancelled that
day. So at least 100 students were in the build-
ing, possibly as many as 120, including a few not
enrolled in the classes. (The statistics are inexact
because not all Norris Hall students responded
to a university survey of their whereabouts that
day.) Of the students present, 25 were killed, 17
were shot and survived, 6 were injured jumping
from windows, and 4 were injured from other
causes.
54

Room 211 suffered the most student casualties
(17). The other rooms with casualties were 207
(11), 206 (11), 204 (10), 205 (1), and 306 (1).
In addition to the classes, there were many other
people in the building at the time of the shoot-
ings, including staff of the deans office, other
faculty members with offices in the building,
other students, and janitorial staff. None of them
was injured.
When the shooting stopped, about 75 students
and faculty were uninjured, some still in class-
room settings and others in offices or hiding in
restrooms. With over 200 rounds left, the toll
could have been higher if the police had not
arrived when they did, as noted earlier.
Table 2 and Table 3 at the end of this chapter
show the numbers of students and faculty who
were killed and injured, by room, based on the
universitys research.
KEY FINDINGS
verall, the police from Virginia Tech and
Blacksburg did an outstanding job in
responding quickly and using appropriate active-
shooter procedures to advance to the shooters
location and to clear Norris Hall.

54
There are small inconsistencies in the tallies of injuries
among police, hospitals, and university because some stu-
dents sought private treatment for minor injuries, and the
definition of injury used.
A
I
O
CHAPTER VIII. MASS MURDER AT NORRIS HALL
99
The close relationship of the Virginia Tech Police
Department and Blacksburg Police Department
and their frequent joint training saved critical
minutes. They had trained together for an active
shooter incident in university buildings. There is
little question their actions saved lives. Other
campus police and security departments should
make sure they have a mutual aid arrangement
as good as that of the Virginia Tech Police
Department.
Police cannot wait for SWAT teams to arrive and
assemble, but must attack an active shooter at
once using the first officers arriving on the scene,
which was done. The officers entering the build-
ing proceeded to the second floor just as the
shooting stopped. The sound of the shotgun blast
and their arrival on the second floor probably
caused Cho to realize that attack by the police
was imminent and to take his own life.
Police did a highly commendable job in starting
to assist the wounded, and worked closely with
the first EMTs on the scene to save lives.
Several faculty members died heroically while
trying to protect their students. Many brave stu-
dents died or were wounded trying to keep the
shooter from entering their classrooms. Some
barricading doors kept their bodies low or to the
side and out of the direct line of fire, which
reduced casualties.
Several quick-acting students jumped from the
second floor windows to safety, and at least one
by dropping himself from the ledge, which
reduced the distance to fall. Other students sur-
vived by feigning death as the killer searched for
victims.
People were evacuated safely from Norris Hall,
but the evacuation was not well organized and
was frightening to some survivors. However,
being frightened is preferable to being injured by
a second shooter. The police had their priorities
correct, but they might have handled the evacua-
tion with more care.
RECOMMENDATIONS
VIII-1 Campus police everywhere should
train with local police departments on
response to active shooters and other emer-
gencies.
VIII-2 Dispatchers should be cautious when
giving advice or instructions by phone to
people in a shooting or facing other threats
without knowing the situation. This is a
broad recommendation that stems from review-
ing other U.S. shooting incidents as well, such as
the Columbine High School shootings. For
instance, telling someone to stay still when they
should flee or flee when they should stay still can
result in unnecessary deaths. When in doubt,
dispatchers should just be reassuring. They
should be careful when asking people to talk into
the phone when they may be overheard by a
gunman. Also, local law enforcement dispatchers
should become familiar with the major campus
buildings of colleges and universities in their
area.
VIII-3 Police should escort survivors out of
buildings, where circumstances and man-
power permit.
VIII-4 Schools should check the hardware
on exterior doors to ensure that they are not
subject to being chained shut.
VIII-5 Take bomb threats seriously. Students
and staff should report them immediately,
even if most do turn out to be false alarms.

CHAPTER VIII. MASS MURDER AT NORRIS HALL
100
Table 2. Norris Hall Student Census for April 16, 2007 9:05 a.m. Classes
Total Students Accounted For:
Used Windows
To
Escape
Room
No.
Total Students
on Class Roll
Killed or
Later
Died Injured
Not Physi-
cally In-
jured
Did Not
Attend
Class
Status
Not
Verified Total
Students
Injured** by
Gunshot Injured*
Not
Injured*
200 14* 0 0 0 14** 0 14 0
204 23 1 9 6 5 2 23 3 6 4
205 14 0 1 8 3 2 14 0
206 14 9 2 2 1 0 14 2
207 15 4 7 1 3 0 15 6
211 22 11 6 0 4 1 22 6
306 37 0 1 20 1 15 37 0
Labs 9 0 0 9 0 0 9 0
Totals 148 25 26 47 31 20 148 17 6 4
* Included in "Total Students Accounted For"
** Class was cancelled that day
Table 3. Norris Hall Faculty Census
Total Faculty Accounted For
Room #
Total
Faculty
Scheduled
Killed or
Later Died Injured
Not Physi-
cally Injured
Did Not At-
tend Class
Status Not
Verified Total
200 1 0 0 0 1** 1
204 1 1 0 0 1
205 1 0 0 1 1
206 1 1 0 0 1
207 1 1 0 0 1
211 1 1 0 0 1
306 1 0 0 1 1
225/hallway 1 1 0 0 1
Totals 8 5 0 2 1 8
* Class was cancelled that day
These tables were provided by the Virginia Tech administration
CHAPTER VIII. MASS MURDER AT NORRIS HALL
100 - A
ADDITIONS AND CORRECTIONS
Cho Surveillance of Norris Hall: Addition In Spring 2007, Cho had a class at Norris
Hall. Between February and April 2007 he was seen numerous times in and around Norris
Hall at times other than when he had class, possibly casing the building. He picked a Monday
for his attack, a day when his class was not in session, which lessened the chance of confront-
ing students and faculty whom he knew and who knew him.
Handling of Bomb Threat Note: p. 89, Correction Cho left a note saying there was a
bomb in Norris Hall not on the inside of one of the chained doors as was stated in the Report,
but rather on the inside of an interior door leading to the vestibule where the exit door was
chained. Also, that note was found by a faculty member and given to a custodian on the second
floor to take to the Deans Office, not carried there by the faculty member herself. Virginia
Tech bomb threat policy required that anyone discovering or receiving a bomb threat should
immediately report the threat to the VTPD.
Doors Shot At: p. 94, Correction Cho had chained all three public entrances to Norris
Hall, using a lock and chain on each. Police tried to get into one of the chained entrances and
then a second. They shot at the lock on the second door but could not break it. The metal chain
was on the inside and there was little play in the door. Police successfully shot open the con-
ventional lock on an exterior door leading to a maintenance shop, from which they gained en-
trance to the rest of Norris Hall. They did not shoot at all three chained doors as reported in
the text.
Student Victim Status: p. 100, Addition The one student in Room 211 of Norris Hall who
was listed in Table 2 as status not verified was later identified as Clay Violand, the only stu-
dent unharmed in that classroom. The total number of people present but unharmed during
the shootings in Norris Hall increases by one, to 47.
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101
Chapter IX.
EMERGENCY MEDICAL SERVICES RESPONSE
he tragic scenes that occurred at Virginia
Tech are the worst that most emergency
medical service (EMS) providers will ever see.
Images of so many students and faculty mur-
dered or seriously injured in such a violent man-
ner and the subsequent rescue efforts can only be
described by those who were there. This chapter
discusses the emergency medical response on
April 16 to victims including their pre-hospital
treatment, transport, and care in hospitals.
Interviews were conducted with first responders,
emergency managers, and hospital personnel
(physicians, nurses, and administrators) to
determine:
The on-scene EMS response.
Implementation of hospital multi-
casualty plans and incident command
systems.
Pre-hospital and in-hospital initial
patient stabilization.
Compliance with the National Incident
Management System (NIMS).
Communications systems used.
Coordination of the emergency medical
care with police and EMS providers.
Evaluating patient care subsequent to the initial
pre-hospital and hospital interventions was
beyond the scope of this investigation. Fire
department personnel were not interviewed
because there were no reports of their
involvement in patient care activities
Although there is always opportunity for
improvement, the overall EMS response was
excellent and the lives of many were saved. The
challenges of systematic response, scene and
provider safety, and on-scene and hospital
patient care were effectively met. Responders are
to be commended. The results in terms of patient
care are a testimony to their medical education
and training for mass casualty events, dedica-
tion, and ability to perform at a high level in the
face of the disaster that struck so many people.
The Virginia Tech Rescue Squad and Blacksburg
Volunteer Rescue Squad were the primary agen-
cies responsible for incident command, triage,
treatment, and transportation. Many other
regional agencies responded and functioned
under the Incident Command System (ICS). The
Blacksburg Volunteer Rescue Squad (BVRS) per-
sonnel and equipment response was timely and
strong. Virginia Tech Rescue Squad (VTRS), the
lead EMS agency in this incident, is located on
the Virginia Tech campus and is the oldest colle-
giate rescue squad of its kind nationwide. It is a
volunteer, student-run organization with 38
members.
55
Their actions on April 16 were heroic
and demonstrated courage and fortitude.
WEST AMBLER JOHNSTON INITIAL
RESPONSE
he first EMS response was to the West
Ambler Johnston (WAJ) residence hall inci-
dent. At 7:21 a.m., VTRS was dispatched to 4040
WAJ for the report of a patient who had fallen
from a loft. In 3 minutes, at 7:24 a.m., VT Rescue
3 was en route. While en route, dispatch advised
that a resident assistant reported a victim lying
against a dormitory room door and that bloody
footprints and a pool of blood were seen on the
floor. VT Rescue 3 arrived on scene at 7:26 a.m.,
5 minutes from the time of dispatch. This
response time falls within the nationally ac-
cepted range.
56


55
VTRS. (2007). April 16, 2007: EMS Response. Presentation
to the Virginia Tech Review Panel. May 21, 2007, The Inn at
Virginia Tech.
56
NFPA (2004). NFPA 1710: Standard for the Organization
and Deployment of Fire Suppression Operations, Emergency
Medical Operations, and Special Operations to the Public by
Career Fire Departments. National Fire Protection Associa-
tion: Battery March Park, MA.
T
T
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
102
At 7:29 a.m., Rescue 3 accessed the dorm room to
find two victims with gunshot wounds, both
obviously in critical condition. At 7:31 a.m., it
requested a second advanced life support (ALS)
unit and ordered activation of the all-call tone
requesting all available Virginia Tech rescue per-
sonnel to respond to the scene. The all-call
request is a normal procedure for VTRS to
respond to an incident with multiple patients.
Personnel from BVRS responded to WAJ as well.
At 7:48 a.m., VT Rescue 3 requested that
Carilion Life-Guard helicopter be dispatched and
was informed that its estimated time of arrival
was 40 minutes. It was decided to dispatch the
helicopter to Montgomery Regional Hospital
(MRH). Carilion Life-Guard then advised that
they were grounded due to weather and never
began the mission.
One of the victims in 4040 WAJ was a 22-year-
old male with a gunshot wound to the head. He
was in cardiopulmonary arrest. CPR was initi-
ated, and he was immobilized using an extrica-
tion collar and a long spine board. VT Rescue 3
transported him to MRH. During communica-
tions with the MRH online physician, CPR was
ordered to be discontinued. He arrived at the
hospital DOA.
57

The second victim was an 18-year-old female
with a gunshot wound to the head. She was
treated with high-flow oxygen via mask, two IVs
were established, and cardiac monitoring was
initiated. She was immobilized with an extrica-
tion collar and placed on a long spine board. At
7:44 a.m., she was transported by VT Rescue 2 to
MRH. During transport, her level of conscious-
ness began to deteriorate and her radial pulse
was no longer palpable.
58
Upon arrival at MRH,
endotracheal intubation was performed. At 8:30
a.m., she was transferred by ground ALS unit to
Carilion Roanoke Memorial Hospital (CRMH), a
Level I trauma center in Roanoke, Virginia.
59


57
EMS Patient Care Report Q0669603.
58
EMS Patient Care Report Q0669604.
59
Turner, K. N., and Davis, J. (2007). Public Safety Timeline
for April 16, 2007. Unpublished Report. Montgomery County
Department of Emergency Services, p. 4.
Following CPR that occurred en route she was
pronounced dead at CRMH.
60

Based on the facts known, the triage, treatment,
and transportation of both WAJ victims
appeared appropriate. The availability of heli-
copter transport likely would not have affected
patient outcomes. Their injuries were incompati-
ble with survival.
NORRIS HALL INITIAL RESPONSE
t 9:02 a.m., VT Rescue 3 returned to service
following the WAJ incident. VT Rescue 2
continued equipment cleanup at MRH when the
call for the Norris Hall shootings came in. At
approximately 9:42 a.m., VTRS personnel at
their station overheard a call on the police radio
advising of an active shooter at Norris Hall.
Many EMS providers were about to respond to
the worst mass shooting event on a United
States college campus.
Upon hearing the police dispatch of a shooting at
Norris Hall, the VTRS officer serving as EMS
commander immediately activated the VTRS
Incident Action Plan and established an incident
command post at the VTRS building. VT Rescue
3, staffed with an ALS crew, stood by at their
station. At about 9:42 a.m., VTRS requested the
Montgomery County emergency services coordi-
nator to place all county EMS units on standby
and for him to respond to the VTRS Command
Post. Standby means that all agency units
should be staffed and ready to respond. Each
agency officer in charge is supposed to notify the
appropriate dispatcher when the units are
staffed.
The Montgomery County Communications Cen-
ter immediately paged out an all call alert (9:42
a.m.) advising all units to respond to the scene at
Norris Hall.
The EMS responses to West Ambler Johnston
and Norris halls occurred in a timely manner.
However, for the shootings at Norris Hall, all
EMS units were dispatched to respond to the

60
EMS Patient Care Report Q0019057.
A
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
103
scene at once contrary to the request. Sub-
sequently, the Montgomery County emergency
services coordinator requested dispatch to correct
the message in time to allow for most of the in-
coming squads to proceed to the secondary stag-
ing area at the BVRS station.
At 9:46 a.m., VTRS was dispatched by police to
Norris Hall for multiple shootings4 minutes
after VTRS monitored the incident (9:42 a.m.) on
the police radio. The VTRS EMS commander
advised VT dispatch that the VTRS units would
stand by at the primary staging site until police
secured the shooting area. At 9:48 a.m., the EMS
commander also requested the VT police dis-
patcher to notify all responding EMS units from
outside Virginia Tech to proceed to the secondary
staging area at BVRS instead of responding
directly to Norris Hall.
The VTPD and the Montgomery County Com-
munications Center issued separate dispatches
for EMS units, which led to some confusion in
the EMS response.
EMS INCIDENT COMMAND SYSTEM
t the national level, Homeland Security
Presidential Directives (HSPDs) 5 and 8
require all federal, state, regional, local, and
tribal governments, including EMS agencies, to
adopt the NIMS, including a uniform ICS.
61
The
Incident Management System is defined by
Western Virginia EMS Council in their Mass
Casualty Incident (MCI) Plan as:
A written plan, adopted and utilized by all
participating emergency response agencies,
that helps control, direct and coordinate
emergency personnel, equipment and other
resources from the scene of an MCI or
evacuation, to the transportation of patients
to definitive care, to the conclusion of the
incident.
62


61
Bush, G. W. (2003). December 17, 2003 Homeland Security
Presidential Directive/HSPD8.
62
WVEMS. (2006). Mass Casualty Incident Plan: EMS
Mutual Aid Response Guide: Western Virginia EMS Council,
Section 2.1.7, p. 2.
Overall, the structure of the EMS ICS was effec-
tive. The ICS as implemented during the inci-
dent is compared in Figure 13 and Figure 14 to
NIMS ICS guidelines. Figure 13 shows the
Virginia Tech EMS ICS structure as imple-
mented in the incident.
63
Although it did not
strictly follow NIMS guidelines, it included most
of the necessary organization. Figure 14 shows
the Model ICS structure based on the NIMS
guidelines.
EMS Command An EMS command post was
established at VTRS. The BVRS officer-in-charge
who arrived at Norris Hall reportedly was
unable to determine if an EMS ICS was in place.
Since each agency has its own radio frequency,
the potential for miscommunication of critical
information regarding incident command is pos-
sible. To enhance communications, EMS com-
mand reportedly switched from the VTRS to the
BVRS radio frequency. In addition, to shift rou-
tine communications from the main VT fre-
quency, EMS command requested units to switch
to alternate frequency, VTAC 1. Some units were
confused by the term VTAC 1. Eventually, all
units switched to the Montgomery County
Mutual Aid frequency.
The fact that BVRS was initially unaware that
VTRS had already established an EMS command
post could have caused a duplication of efforts
and further organizational challenges. Partici-
pants interviewed stated that once a BVRS offi-
cer reported to the EMS command post, commu-
nications between EMS providers on the scene
improved. The Montgomery County emergency
management coordinator was on the scene and
served as a liaison between the police tactical
command post and the EMS incident command
post, which also helped with communications.
Because BVRS and VTRS are on separate pri-
mary radio frequencies, BVRS reportedly did not
know where to stage their units. In addition,
BVRS units reportedly did not know when the
police cleared the building for entry.

63
VTRS. (2007). April 16, 2007: EMS Response. Presentation
to the Virginia Tech Review Panel. May 21, 2007, The Inn at
Virginia Tech.
A

104

Figure 13. Virginia Tech EMS ICS as Implemented in the Incident

Another issue concerned the staging of units
and personnel. EMS command correctly advised
dispatch that assignments and staging would be
handled by EMS command.
64

Triage The VTPD arrived at Norris Hall at
9:45 a.m. At 9:50 a.m., the VTPD and Blacks-
burg police emergency response teams (ERTs)
arrived at Norris Hall, each with a tactical
medic. At 9:50 a.m., two ERT medics entered
Norris Hall where they were held for about 2
minutes inside the stairwell before being al-
lowed to proceed. At 9:52 a.m., the two medics,
one from VTRS and one from BVRS, began tri-
age. Medics initially triaged those victims
brought to the stairwells while police were mov-
ing them out of the building. As victims exited

64
Turner, K.N., & Davis, J. (2007). Public Safety Timeline
for April 16, 2007. Unpublished Report. Montgomery County
Department of Emergency Services, p. 6.
the building, some walked and some were car-
ried out and transported by police SUVs and
other mobile units to the safer EMS treatment
areas.
The triage by ERT medics inside the Norris Hall
classrooms had two specific goals: first, to iden-
tify the total number of victims who were alive
or dead; and second, to move ambulatory vic-
tims to a safe area where further triage and
treatment could begin. The tactical medics em-
ployed the START triage system (Simple Triage
and Rapid Treatment) to quickly assess a victim
and determine the overall incident status. The
START triage is a method whereby patients in
an MCI are assessed and evaluated on the basis
Virginia Tech Rescue
Squad EMS
Command
Virginia Tech Rescue
Squad EMS
Operations Chief
Montgomery County
ESCPolice
Command Post
Liaison
Treatment Officer
Tertiary Triage
Triage Officer
Triage Teams
Primary
Triage
Secondary
Triage
Staging Officer
Primary Staging
(on campus)
Secondary
Staging
(Station 1)
Virginia Tech Rescue
Squad EMS
Command
Virginia Tech Rescue
Squad EMS
Operations Chief
Montgomery County
ESCPolice
Command Post
Liaison
Treatment Officer
Tertiary Triage
Triage Officer
Triage Teams
Primary
Triage
Secondary
Triage
Staging Officer
Primary Staging
(on campus)
Secondary
Staging
(Station 1)
Treatment Officer
Tertiary Triage
Treatment Officer
Tertiary Triage
Triage Officer
Triage Teams
Primary
Triage
Secondary
Triage
Triage Officer
Triage Teams
Primary
Triage
Secondary
Triage
Staging Officer
Primary Staging
(on campus)
Secondary
Staging
(Station 1)
Staging Officer
Primary Staging
(on campus)
Secondary
Staging
(Station 1)
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
105
Figure 14. Model ICS Based on the NIMS Guidelines

of the severity of injuries and assigned to treat-
ment priorities.
65
Patients are classified in one
of four categories (Figure 15). Colored tags are
affixed to patients corresponding to these catego-
ries.
In an incident of this nature, the triage team
must concentrate on the overall situation instead

65
WVEMS. (2006). Mass Casualty Incident Plan: EMS
Mutual Aid Response Guide: Western Virginia EMS Council,
Section 2.1.8, p. 2.
Immediate
Delayed
Minor
Deceased
66

Figure 15. START Triage Patient Classifications

66
Critical Illness and Trauma Foundation, Inc. (2001).
STARTSimple Triage and Rapid Treatment.
http://www.citmit.org/start/default.htm
EMS Command
VT Rescue
VT Lieutenant
Safety Officer
Norris Hall
Blacksburg Lt.
Liaison Officer
Norris Hall
Montgomery Co.
Coord.
PIO
Police
Operations Chief
VT Rescue
VT Lieutenant
Logistics Chief
VT Rescue
VT Lieutenant
Planning Chief
VT EMS Command
Finance/Admin
VT University Staff
Base
Blacksburg
Rescue
Staging Manager
VT Rescue
Triage Group
Norris Hall
VT Captain
Treatment Group
Norris Hall
VT Lieutenant
Transportation
Group
VT Rescue
Morgue Unit
Norris Hall
Blacksburg Lt.
Initial Triage Unit
Norris Hall
Tactical Medics
Major Treatment
Unit
Norris Hall
Lieutenant
Delayed
Treatment Unit
Barger Street
Minor Treatment
Unit
VT Rescue
Squad
Patient Dispatch
Manager
VT Rescue
Squad
EMT
Medical
Communicator
EMS Command
VT Rescue
VT Lieutenant
Safety Officer
Norris Hall
Blacksburg Lt.
Liaison Officer
Norris Hall
Montgomery Co.
Coord.
PIO
Police
Operations Chief
VT Rescue
VT Lieutenant
Logistics Chief
VT Rescue
VT Lieutenant
Planning Chief
VT EMS Command
Finance/Admin
VT University Staff
Base
Blacksburg
Rescue
Staging Manager
VT Rescue
Triage Group
Norris Hall
VT Captain
Treatment Group
Norris Hall
VT Lieutenant
Transportation
Group
VT Rescue
Morgue Unit
Norris Hall
Blacksburg Lt.
Initial Triage Unit
Norris Hall
Tactical Medics
Major Treatment
Unit
Norris Hall
Lieutenant
Delayed
Treatment Unit
Barger Street
Minor Treatment
Unit
VT Rescue
Squad
Patient Dispatch
Manager
VT Rescue
Squad
EMT
Medical
Communicator
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
106
of focusing on individual patient care. Patient
care is limited to quick interventions that will
make the difference between life and death. The
medics systematically approached the initial tri-
age, with one assessing victims in the odd-
numbered rooms on the second floor of Norris
Hall while the other assessed victims in the
even-numbered rooms. The medics were able to
quickly identify those victims who were without
vital signs and would likely not benefit from
medical care. This initial triage by the two tacti-
cal medics accompanying the police was appro-
priate in identifying patient viability. The medics
reported a tough time with radio communica-
tions traffic while triaging in Norris Hall.
The triage medics identified several patients who
required immediate interventions to save their
lives. Some victims with chest wounds were
treated with an Asherman Chest Seal (Figure
16). It functions with a flutter valve to prevent
air from entering the chest cavity during inhala-
tion and permits air to leave the chest cavity
during exhalation. This is a noninvasive tech-
nique that can be applied quickly with low risk.
It was reported that a female victim with chest
wounds benefited by the immediate application
of the seal. Since the scene was not yet secured
at this point to allow other EMS providers to
enter, the tactical medics quickly instructed
some police officers how to use the seal.
Figure 16. Asherman Chest Seal
67


67
ACS (2007). Asherman Chest Seal.
http://www.compassadvisors.biz
A decision was quickly made to treat a 22-year-
old male victim who exhibited a profuse femoral
artery bleed by applying a commercial-brand
tourniquet (Figure 17) to control the bleeding.
The patient was transported to MRH, where sur-
gical repair was performed and he survived. The
application of a tourniquet was likely a lifesaving
event.

Figure 17 Tourniquet
68

At approximately 10:09 a.m., VTPD dispatch
notified EMS command that the shooter was
down and that EMS crews could enter Norris
Hall. EMS command assigned a lieutenant from
VTRS to become the triage unit leader. Triage
continued inside and in front of Norris Hall.
Some critical patients at the Drillfield side and
others at the secondary triage (critical treatment
unit) Old Turner Street side of Norris Hall were
placed in ambulances and transported directly to
hospitals. Noncritical patients were moved to a
treatment area at Stanger and Barger Streets.
A BVRS officer and crew arrived at Norris Hall
and began to retriage victims. Their reassess-
ment confirmed that 31 persons were dead.
Based on the evidence available, the decision not
to attempt resuscitation on those originally tri-
aged as dead was appropriate. No one appeared
to have been mistriaged. A medical director
(emergency physician) for a Virginia State Police
Division SWAT team responded with his team to
the scene. He was primarily staged at Burress
Hall and was available to care for wounded

68
Medgadget (2007). http://www.medgadget.com
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
107
officers if needed. There were no reports of inju-
ries to police officers.
Interviews of prehospital and hospital personnel
revealed that triage ribbons or tags were not
consistently used on victims. The standard triage
tags were used on some patients but not on all.
These triage tags, shown in Figure 18, are part of
the Western Virginia EMS Trauma Triage
Protocol and can assist with record keeping and
patient follow-up.
69
Not using the tags may have
led to some confusion regarding patient
identification and classification upon arrival at
hospitals.
Treatment Patients were moved to the
treatment units based on START guidelines. The
treatment group was divided into three units: a
critical treatment unit, a delayed treatment unit
and a minor treatment unit. The critical treat-
ment unit was located at the Old Turner Street
Side of Norris Hall where patients with immedi-
ate medical care needs (red tag) received care.
Patients who were classified as less critical (yel-
low tag) were moved to the delayed treatment
unit at Stanger and Barger Streets. Patients
with minor injuries, including walking wounded/
worried well (green tag) were moved to a minor
treatment unit at VTRS (Figure 19). Worried
well are those who may not present with inju-
ries but with psychological or safety issues.
Patients were moved to the treatment units in
various ways. Some critical patients were carried
out of Norris Hall by police and EMS personnel.
Others were moved via vehicles, while those less
critical walked to the delayed treatment or minor
treatment units. EMS command assigned leaders
to each of the units.
The weather was a significant factor with wind
gusts of up to 60 mph grounding all aeromedical
services and hampering the use of EMS equip-
ment. This included tents, shelters, and treat-
ment area identification flags that could not be

69
WVEMS. (2006). Mass Casualty Incident Plan: EMS
Mutual Aid Response Guide: Western Virginia EMS Council.,
Section 22.3, p. 13.
Figure 18. Virginia Triage Tag
set up or maintained. Large vehicles such as
trailers and mobile homes, often used for tempo-
rary shelter, had difficulty responding as high
winds made interstate driving increasingly haz-
ardous. The incident site was close to ongoing
construction. High winds blew debris, increasing
danger to patients and providers and impeding
patient care. To protect the walking wounded/
worried well from the environment, patients
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
108
Figure 19. Initial Location of Treatment Units
were moved to the minor treatment unit at the
VTRS building.
Twelve EMS patient care reports (PCRs) were
available for review. In some cases PCRs were
not completed, and in other cases not provided
upon request. In multiple casualty incident
situations, EMS providers can use standard tri-
age tags in place of the traditional PCR; how-
ever, no triage tag records were provided, as
noted earlier.
Based on the PCRs available and the interviews
of EMS and hospital personnel, it appears that
the patient care rendered to Norris Hall victims
was appropriate.
Transportation EMS command appointed
a transportation group leader who assigned
patients to ambulances and specific hospital
destinations. Christiansburg Rescue Squad
(CRS) responded with BLS and ALS units and
was among the first in line at Norris Hall. CRS,
BVRS, CPTS, and LongshopMcCoy Rescue
Squad transported critical patients to area hos-
pitals. CPTS ambulances from Giles, Radford,
and Blacksburg as well as some of their
Roanoke-based units, including Life-Guard
flight and ground critical care crews, responded
in mass to the incident either at Norris Hall or
by interfacility transport of critical victims. By
10:51 a.m., all patients from Norris Hall were
either transported to a hospital, or moved to the
delayed or minor treatment units. In addition to
VTRS, 14 agencies responded to the incident
with 27 ALS ambulances and more than 120
EMS personnel (Table 4). Some agencies
delayed routine interfacility patient transports
or back filled covering neighboring communi-
ties through preset mutual aid agreements.
Agency supervisors and administrators were
working effectively behind the scenes procuring
A/B: Staging Areas
C: Command Post
D: Treatment Area
(Delayed and Minor
Treatment Units)
E: Secondary Triage
(Critical Treatment
Unit)
C
A
D
B
E
A/B: Staging Areas
C: Command Post
D: Treatment Area
(Delayed and Minor
Treatment Units)
E: Secondary Triage
(Critical Treatment
Unit)
C
A
D
B
E
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
109
Table 4. EMS Response
14 Assisting Agencies
70

Montgomery County Emergency Services
Coordinator
Blacksburg Volunteer Rescue Squad
Christiansburg Rescue Squad
Shawsville Rescue Squad
Longshop-McCoy Rescue Squad
Carilion Patient Transportation Services
Salem Rescue Squad
Giles Rescue Squad
Newport Rescue Squad
Lifeline Ambulance Service
Roanoke City Fire and Rescue
Vinton First Aid Crew
Radford University EMS
City of Radford EMS
the necessary resources and supporting the
response of their EMS crews. These agencies
demonstrated an exceptional working relation-
ship, likely an outcome of interagency training
and drills.
False Alarm Responses At 10:58 a.m., EMS
command was notified of a reported third shoot-
ing incident at the tennis court area on Wash-
ington Street that proved to be a false alarm. At
11:18 a.m., EMS command was notified of a
bomb threat at Norris and Holden Halls that
also proved to be false. Due to safety concerns,
EMS command ordered the staging area moved
from Barger St. to Perry St.
Post-Incident Transport of the Deceased
At 4:03 p.m., the medical examiner authorized
removal of the deceased from Norris Hall to the
medical examiners office in Roanoke. Due to
another rescue incident in the Blacksburg area,
units were not available until 5:15 p.m. to begin
transport of the deceased. Several options were
considered including use of a refrigeration
truck, funeral coaches, or EMS units. EMS
command, in consultation with the medical
examiners representative, determined that

70
VTRS. (2007). April 16, 2007: EMS Response. Presenta-
tion to the Virginia Tech Review Panel. May 21, 2007, The
Inn at Virginia Tech.
EMS units from several companies would trans-
port the deceased to Roanoke. In general, front-
line EMS units are not used to transport the
deceased. In this instance, however, the use of
EMS units was acceptable because emergency
coverage was not neglected and the rescuers felt
that the sight of a refrigeration truck and
funeral coaches on campus would be undesir-
able.
The decedents were placed two to a unit for
transport. A serious concern raised by EMS pro-
viders was an order given by an unidentified
police official that the decedents be transported
to Roanoke under emergency conditions (lights
and sirens). Due to safety considerations, EMS
command modified this order.
The police order to transport the deceased under
emergency conditions from Norris Hall to the
medical examiners office in Roanoke was in-
appropriate for several reasons:
It is not within law enforcements scope
of practice to order emergency transport
(red lights and siren) of the deceased.
There was no benefit to anyone by
transporting under emergency condi-
tions.
A 30-minute or longer drive to Roanoke,
during bad weather, with winds gusting
above 60 mph, exposes EMS personnel
to unnecessary risks.
Transporting under emergency condi-
tions increases the possibility of vehicle
crashes with risk to civilians.
Critical Incident Stress Management
Although no physical injuries were reported,
psychological and stress- related issues can sub-
sequently manifest in EMS providers. Local and
regional EMS providers participated in critical
incident stress management activities such as
defusings and debriefings immediately post-
incident.
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
110
HOSPITAL RESPONSE
atients from Virginia Tech were treated at
five area hospitals:
Montgomery Regional Hospital
Carilion New River Valley Hospital
LewisGale Medical Center
Carilion Roanoke Memorial Hospital
Carilion Roanoke Community Hospital
Twenty-seven patients are known to have been
treated by local emergency departments. Some
others who were in Norris Hall may have been
treated at other hospitals, medical clinics, or
doctors offices including their own primary care
providers; but there are no known accounts.
Overall, the local and regional hospitals quickly
implemented their hospital ICS and mobilized
resources. Aggressive measures were taken to
postpone noncritical procedures, shift essential
personnel to critical areas, reinforce physician
staffing, and prepare for patient surge. Three
hospitals initiated their hospital-wide emer-
gency plans. One hospital, a designated Level I
trauma center, did not feel that a full-scale,
hospital-wide implementation of their emer-
gency plan was necessary.
The most significant challenge early on was the
lack of credible information about the number of
patients each expected to receive. The emer-
gency departments did not have a single official
information source about patient flow. Likely
explanations for this were (1) an emergency
operations center (EOC) was not opened at the
university, and (2) the Regional Hospital Coor-
dinating Center did not receive complete infor-
mation that it should have under the MCI
plan.
71

Preparedness, patient care/patient flow, and
patient outcomes were reviewed for each of the
receiving hospitals.

71
Personal communications, Morris Reece, Near Southwest
Preparedness Alliance, June 15, 2007.
Montgomery Regional Hospital The
MRH emergency department, a Level III
trauma center, received 17 patients from the
Virginia Tech incident; two from West Ambler
Johnston and 15 from Norris Hall. The patients
from WAJ arrived at 7:51 and 7:55 a.m. The
first patient from WAJ was the 22-year-old male
with a gunshot wound to the head who was
DOA. No further attempts at resuscitation were
made in the emergency department.
The second patient from WAJ was the 18-year-
old female who arrived in critical condition with
a gunshot wound to the head. Upon arrival to
the emergency department, she was unable to
speak and her level of consciousness was dete-
riorating. Airway control via endotracheal intu-
bation was achieved using rapid sequence in-
duction. At 8:30 a.m., she was transported by
ALS ambulance to Carilion Roanoke Memorial
Hospital, the Level I trauma center for the
region. She died shortly after arrival at CRMH.
HOSPITAL PREPAREDNESS: At 9:45 a.m., MRH
was notified of shots fired somewhere on the
Virginia Tech campus. Because they were un-
sure of the number of shooters or whether the
incident was confined to campus, MRH initiated
a lockdown procedure. Since the killing of a hos-
pital guard at MRH in August 2006 (the Morva
incident mentioned in Chapter VII), there has
been heightened awareness at MRH regarding
security procedures. At 10:00 a.m., information
became available confirming multiple gunshot
victims. A code green (disaster code) was initi-
ated and the following actions were taken:
The hospital incident command center
was opened and preassigned personnel
reported to command.
The hospital facility was placed on a
controlled access plan (strict lockdown).
Only personnel with appropriate identi-
fication (other than patients) could enter
the hospital and then only through one
entrance.
All elective surgical procedures were
postponed.
P
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
111
Day surgery patients with early surgery
times were sent home as soon as possi-
ble.
The emergency department was placed
on divert for all EMS units except those
arriving from the Norris Hall incident.
The emergency department was staffed
at full capacity. A rapid emergency
department discharge plan was insti-
tuted. Stable patients were transferred
from the emergency department to the
outpatient surgery suite.
At 10:05 a.m., the first patient from Norris Hall
arrived via self-transport. This patient was
injured escaping from Norris Hall. MRH was
unable to determine the extent of the Norris
Hall incident based on the history and minor
injuries of this patient. The Regional Hospital
Coordinating Center (RHCC) was notified of the
incident and asked to open. Although the RHCC
had early notification of the incident, they too
were not able to ascertain the extent of the cri-
sis initially.
At 10:14 and 10:15 a.m., two EMS-transported
patients from Norris Hall arrived. It was evi-
dent that MRH might continue to receive
expected and unexpected patients. In prepara-
tion for the surge, MRH took the following addi-
tional actions:
The Red Cross was alerted and the blood
supply reevaluated.
Additional pharmaceutical supplies and
a pharmacist were sent to the emer-
gency department.
A runner was assigned to assist with
bringing additional materials to and
from the emergency department and the
pharmacy.
Disaster supply carts were moved to the
hallways between the emergency
department and outpatient surgery.
72


72
Montgomery Regional Hospital. (2007). Montgomery
Regional Hospital VT Incident Debriefing. April 23, 2007,
p. 1.
At 10:30 a.m. as the above actions were being
taken, four more gunshot victims arrived via
EMS transport from Norris Hall. Between 10:45
and 10:55 a.m., five additional patients arrived
via EMS. Command designated a public infor-
mation officer and, by 11:00 a.m., a base had
been established where staff and counselors
could assist family and friends of patients.
By 11:15 a.m., MRH was still unclear about how
many additional patients to expect. (They had a
total of 12 by this time.) The operations chief
instructed an emergency administrator to
respond to the Virginia Tech incident as an on-
scene liaison to determine how many more
patients would be transported to MRH. At 11:20
a.m., the emergency department administrator
reported to the Virginia Tech command center.
MRH said that the face-to-face communications
were helpful in determining how many addi-
tional patients to expect.
At 11:40 a.m., MRH received its last gunshot
victim from the incident. By 11:51 a.m., its on-
scene liaison confirmed that all patients had
been transported. At 12:12 p.m., the EMS divert
was lifted. At 13:04 and 13:10 p.m., however,
two additional patients from the incident
arrived by private vehicle. At 13:35 p.m., the
code green was lifted.
Patient Care/Patient Flow/Patient Outcomes: In all,
15 patients arrived at MRH from the Norris
Hall incident (Table 5) and were managed well.
An emergency department (ED) nurse/EMT-C
was assigned to online medical direction and
assisted with directing patients to other hospi-
tals. EMS was instructed to transport four
patients to Carilion New River Valley Hospital
and five patients to LewisGale Medical Center.
One patient from the Norris Hall incident was
transferred from MRH to CRMH in Roanoke.
The hospital representatives reported that there
were problems with patient identification and
tracking. As noted earlier:
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
112
Table 5. Norris Hall Victims Treated by
Montgomery Regional Hospital
Injuries Disposition
GSW left hand fractured
4th finger
OR and admission
GSW to right chest
hemothorax
Chest tube in OR and
admission
GSW to right flank OR and admission to
ICU
GSW left elbow, right thigh Admitted
GSW x 2 to left leg OR and admission
GSW right bicep Treated and discharged
GSW right arm, grazed chest
wall; abrasion to left hand
Admitted
GSW right lower extremity;
laceration to femoral artery
OR and ICU
GSW right side abdomen
and buttock
OR and ICU
GSW right bicep Treated and discharged
GSW to face/head Intubated and trans-
ferred to CRMH
Asthma attack precipitated
by running from building
Treated and discharged
Tib/fib fracture due to jump-
ing from a 2
nd
-story window
OR and admission
First-degree burns to chest
wall
Treated and discharged
Back pain due to jumping
from a 2nd-story window
Treated and discharged
An EOC was not activated at Virginia
Tech. Establishing an EOC can enhance
communications and information flow to
hospitals.
Triage tags were not used for all
patients. This would have provided a
discrete number for identifying and
tracking each patient.
MRH activated its ICS as shown in Figure 20.
ACCOMMODATIONS FOR PATIENTS FAMILIES AND
FRIENDS: MRH accommodated families and
friends of patients they treated in their emer-
gency department. MRH was challenged by the
need to provide assistance to those who were
unsure of the status or location of persons they
were trying to find (possibly victims). An open
space on the first floor was used for family and
friends to gather. Since Virginia Tech had not
yet opened an EOC or family assistance center,
some victims family and friends chose to pro-
ceed to the closest hospital. Several family
members and friends of victims came to MRH
even though their loved ones were never trans-
ported there.
A psychological crisis counseling team was
assembled at MRH to provide services to vic-
tims, their families and loved ones, and hospital
staff.
73
Virginia State Police troopers were
assigned to the hospital and were helpful in
maintaining security.
At 11:30 a.m., a surgeon arrived from Lewis
Gale Hospital and was emergently credentialed
by the medical staff office. This is notable as
LewisGale and MRH are not affiliated.
Police departments often rely on hospitals to
help preserve evidence and maintain a chain of
custody. MRH was able to gather evidence in
the emergency department and operating
rooms, including bullets, clothing, and patient
identification. At 1:45 p.m., the Virginia State
Police notified the hospital that all bullets and
fragments were to be considered evidence.
Internal communications issues included:
The Nextel system was overwhelmed.
Clinical directors were too busy to
retrieve and respond to messages.
Monitoring EMS radio communications
was difficult due to noise and chatter.
There was deficient communications be-
tween the university and MRH.
An EOC could have been helpful with
communications


73
Heil, J. et al. (2007). Psychological Intervention with the
Virginia Tech Mass Casualty: Lessons Learned in the Hospi-
tal Setting. Report to the Virginia Tech Review Panel.
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
113
Incident Commander
PIO Marketing
Liaison Officer
Dir. Emergency Mgmt.
Safety Officer
Director Safety/Security
Medical/Technical
Specialist(s)
Finance Section Chief
CFO
Time Unit Leader
Procurement Unit
Leader
Compensation/Claims
Unit Leader
Cost Unit Leader
Operations Chief
CNO
Staging Manager
Personnel Staging Team
Vehicle Staging Team
Equipment/Supply Staging Team
Medication Staging Team
Medical Care Director
ED Director
Triage Unit Leader
(ED RN/Surgeon)
Immediate Care Unit Leader
(ED Charge Nurse)
Delayed/Minor Unit Leader
(ED RN/NP)
Infrastructure Branch
Director
Power/Lighting Unit
Water/Sewer Unit
HVAC Unit
Building/Grounds Damage Unit
Medical Gases Unit
Medical Devices Unit
Environmental Services Unit
Food Services Unit
Hazmat Branch Director
Detection and Monitoring Unit
Spill Response Unit
Victim Decontamination Unit
Facility/Equipment
Decontamination Unit
Security Branch
Director
Access Control Unit
Crowd Control Unit
Traffic Control Unit
Search Unit
Law Enforcement Interface Unit
Business Continuity
Branch Director
Information Technology Unit
Service Continuity Unit
Records Preservation Unit
Business Function Relocation Unit
Planning Chief
CEO/Director Emergency Mgmt.
Documentation Unit
Leader
Demobilization Unit
Leader
Resources Leader
Director Material Mg.
Personnel Tracking
Material Tracking
Situation Unit Leader
Patient Tracking
Bed Tracking
Logistics Chief
CEO
Services Branch
Director
Communications Unit
IT/IS Unit
Staff Food & Water Unit
Support Branch
Director
Employee Health & Well-Being Unit
Family Care Unit
Supply Unit
Facilities Unit
Transportation Unit
Labor Pool & Credentialing Unit
Biological/Infectious Disease
Chemical
Radiological
Clinic Administration
Hospital Administration
Legal Affairs
Risk Management
Medical Staff
Pediatric Care
Medical Ethicist
Incident Commander
PIO Marketing
Liaison Officer
Dir. Emergency Mgmt.
Safety Officer
Director Safety/Security
Medical/Technical
Specialist(s)
Finance Section Chief
CFO
Time Unit Leader
Procurement Unit
Leader
Compensation/Claims
Unit Leader
Cost Unit Leader
Operations Chief
CNO
Staging Manager
Personnel Staging Team
Vehicle Staging Team
Equipment/Supply Staging Team
Medication Staging Team
Medical Care Director
ED Director
Triage Unit Leader
(ED RN/Surgeon)
Immediate Care Unit Leader
(ED Charge Nurse)
Delayed/Minor Unit Leader
(ED RN/NP)
Infrastructure Branch
Director
Power/Lighting Unit
Water/Sewer Unit
HVAC Unit
Building/Grounds Damage Unit
Medical Gases Unit
Medical Devices Unit
Environmental Services Unit
Food Services Unit
Hazmat Branch Director
Detection and Monitoring Unit
Spill Response Unit
Victim Decontamination Unit
Facility/Equipment
Decontamination Unit
Security Branch
Director
Access Control Unit
Crowd Control Unit
Traffic Control Unit
Search Unit
Law Enforcement Interface Unit
Business Continuity
Branch Director
Information Technology Unit
Service Continuity Unit
Records Preservation Unit
Business Function Relocation Unit
Planning Chief
CEO/Director Emergency Mgmt.
Documentation Unit
Leader
Demobilization Unit
Leader
Resources Leader
Director Material Mg.
Personnel Tracking
Material Tracking
Situation Unit Leader
Patient Tracking
Bed Tracking
Logistics Chief
CEO
Services Branch
Director
Communications Unit
IT/IS Unit
Staff Food & Water Unit
Support Branch
Director
Employee Health & Well-Being Unit
Family Care Unit
Supply Unit
Facilities Unit
Transportation Unit
Labor Pool & Credentialing Unit
Biological/Infectious Disease
Chemical
Radiological
Clinic Administration
Hospital Administration
Legal Affairs
Risk Management
Medical Staff
Pediatric Care
Medical Ethicist
Figure 20. Montgomery Regional Hospital ICS

CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
114
Carilion New River Valley Hospital
CNRVH is a Level III trauma center that
received four patients with moderate to severe
injuries.
Hospital Preparedness: CNRVH initially heard
unofficial reports of the WAJ shootings. They
heard nothing further for over 2 hours until
they received a call from MRH and also from an
RN/medic who was on scene. They were called
again later by MRH and advised that they
would be receiving patients with extremity
injuries. They were also notified that MRH was
on EMS divert.
While waiting for patients to arrive, the emer-
gency department (ED) physician medical direc-
tor assumed responsibility for the regular ED
patients while the on-duty physicians were pre-
paring to treat patients from Norris Hall. The
on-duty hospitalist (a physician who is hired by
the hospital to manage in-patient care needs)
reported to the ED to make rapid decisions on
whether current patients would be admitted or
discharged.
The hospital declared a code green and their
EOC was opened at 11:50 a.m. The incident
commander was a social worker who had special
training in hospital ICS. Security surveyed all
patients with a metal detection wand because
they were unsure who may be victims or perpe-
trators. A SWAT team from Pulaski County
responded to assist with security.
PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES:
Four patients were transported by EMS to
CNRVH, each having significant injuries. The
hospital managed the patients well and could
have handled more. Table 6 lists the patient
injuries and dispositions.
Accommodations for Patients Families and Friends:
The hospital received many phone calls concern-
ing the whereabouts of Virginia Tech shooting
victims. Communications issues, particularly
the lack of accurate information, were a big con-
cern for the hospital; while providing accommo-
dations for patients families and friends and
assisting others who were looking for their loved
ones.
Table 6. Norris Hall Victims Treated by Carilion New
River Valley Hospital
Injuries Disposition
GSW to face, pre-auricular
area, bleeding from external
auditory canal, GCS of 7, poor
airway, anesthesiologist rec-
ommended surgical airway
Surgical cricothyro-
tomy
Transferred to CRMH
by critical care ALS
ambulance
GSW to flank and right arm,
hypotensive
Immediately taken to
OR; small bowel
injury/resection
GSW to posterior thorax (exit
right medial upper arm), addi-
tional GSWs to right buttock,
and left lateral thigh
To OR for surgical
repair of left femur
fracture
GSW to right lateral thigh, exit
thru right medial thigh, lodged
in left medial thigh
Admitted in stable
condition and
observed; no vascular
injuries
LewisGale Medical Center LGMC, a
community hospital, received five patients from
the Norris Hall shootings. The ICS structure
used and their emergency response to the inci-
dent were appropriate. Multiple casualty inci-
dents and use of the ICS were not new to
LGMC. Their ICS had been recently tested after
an outbreak of food poisoning at a local college.
Hospital Preparedness: LGMC first became
aware of the Norris Hall incident when a call
was received requesting a medical examiner.
They were unable to fulfill the request. At 11:10
a.m., they received a call from Montgomery
Regional Hospital advising them of the incident.
LGMC immediately declared a code aster,
which is their disaster plan.
The code aster was announced throughout the
hospital, the EOC was opened, and the ICS was
initiated. At 11:16 a.m., they were notified that
MRH was on EMS diversion. At 11:32 a.m., they
were notified that they were receiving their first
patient suffering from a gunshot wound. In
addition to preparing for the patients to arrive
at their own hospital, LGMC sent a surgeon to
MRH to assist with the surge of surgical
patients there.
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
115
PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES:
EMS transported five patients from the Norris
Hall shootings to LGMC. Table 7 lists the
patient injuries and dispositions. These patients
were well managed.
Table 7. Norris Hall Victims Treated by
LewisGale Medical Center
Injuries Disposition
GSW grazed shoulder and
lodged in occipital area, did
not enter the brain
Patient taken to sur-
gery by ENT for
debridement
GSW in back of right arm,
bullet not removed
Patient admitted for
observation
GSW to face, bullet fragment
in hair, likely secondary to
shrapnel spray
Treated in ED and
released
J umped from Norris Hall, 2nd
floor, shattered tib/fib
Admitted, taken to sur-
gery the next day
J umped from Norris Hall, 2nd
floor, soft tissue injuries,
neck and back sprain, re-
portedly was holding hands
with another jumper
Treated in ED and
released
Accommodation for Patients Family and Friends: No
specific information was obtained from LGMC
about accommodations for patients families and
friends. However, the hospitals needs for accu-
rate information while accommodating patient
families and friends and assisting
others in attempting to locate loved ones are
similar for all emergency departments in times
of mass casualty incidents.
Carilion Roanoke Memorial Hospital
This Level I trauma facility located in Roanoke
received three critical patients transferred from
local hospitals. Two patients were transported
from MRH (one from the WAJ incident and one
from the Norris Hall incident). The third patient
was transferred from CNRVH (from the Norris
Hall incident).
HOSPITAL PREPAREDNESS: CRMH did not initiate
its hospital-wide disaster plan since standard
procedures allowed for effective incident man-
agement with the relatively small number of
patients received. They did initiate a gold
trauma alert that brings to the ED three
nurses, one trauma attending physician, one
trauma fellow physician, one radiologist, one
anesthesiologist, and a lab technician.
In addition to the patient transfers, CRMH
received a trauma patient from another inci-
dent. The ED had three other emergency physi-
cians physically present with others on standby.
A neurosurgeon was also in the ED awaiting the
arrival of transfer patients.
CRMHs concerns echoed those of the other hos-
pitals who received patients from the Virginia
Tech incident, including lack of clarity as to
expected patient surge and the need for better
regional coordination. It was suggested that the
RHCC Mobile Communications Unit could have
been dispatched to the scene.
Patient Care/Patient Flow/Patient Outcomes: CRMH
appropriately triaged and managed well the pa-
tients they received. Adequate staffing and op-
erating rooms were immediately available. Ta-
ble 8 lists WAJ and Norris Hall victims treated
at CRMH.
Table 8. WAJ and Norris Hall Victims Treated by
Carilion Roanoke Memorial Hospital
Injuries Disposition
Transfer from MRH, se-
vere head injury
Pronounced dead in ED
Transfer from MRH, head
and significant facial/jaw
injuries, subsequent oro-
tracheal intubation
Patient taken to OR for
surgery, subsequently
transferred to a facility
closer to home
Transfer from CNRVH,
GSW to face, subsequent
cricothyrotomy
Patient taken to OR for
surgery
Carilion Roanoke Community Hospital
CRCH is a community hospital located near
and associated with CRMH. CRCH treated a
self-transported student who was injured by
jumping from Norris Hall. Table 9 lists the inju-
ries and disposition of this patient.
Table 9. Norris Hall Victim Treated by Carilion
Roanoke Community Hospital
Injuries Disposition
Ankle contusion and sprain
secondary to jumping
Treated and released
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
116
EMERGENCY MANAGEMENT
ulticasualty incidents often require coor-
dination among state, regional, and local
authorities. This section reviews the inter-
relationships of these authorities.
Virginia Department of Health In 2002,
the Virginia Department of Health (VDH) was
awarded funding from the Health Resources and
Services Administration (HRSA) National
Bioterrorism Hospital Preparedness Program
(NBHPP) for enhancement of the health and
medical response to bioterrorism and other
emergency events. As part of this process, VDH
developed a contract with the Virginia Hospital
and Healthcare Association (VHHA) to manage
the distribution of funds from the HRSA grant
to state acute care hospitals and other medical
facilities and to monitor compliance. A small
percentage of the HRSA funds were used within
VDH to fund a hospital coordinator position, as
well as to partially fund a deputy commissioner
and other administrative positions. Substan-
tially more than 85 percent of this HRSA grant
funding was distributed to hospitals or used for
program enhancement, including development
of a web-based hospital status monitoring sys-
tem, multidisciplinary training activities,
behavioral health services, and poison control
centers.
At the same time, VDH received separate fund-
ing from the Centers for Disease Control and
Prevention (CDC) for the enhancement of public
health response to bioterrorism and other emer-
gency events. The position of VDH Deputy
Commissioner for Emergency Preparedness and
Response was created, with responsibility for
both CDC and HRSA emergency preparedness
funds. The physician in this position reports
directly to the state health commissioner, who
serves as the state health officer for Virginia.
74


74
Kaplowitz, L, Gilbert, C. M., Hershey, J. H., and Reece,
M. D. (2007). Health and Medical Response to Shooting
Episode at Virginia Tech, April, 2007: A Successful
Approach. Unpublished Manuscript. Virginia Department of
Health, p. 2.
The Virginia Department of Health regional
planning approach aligns hospitals with health
department planning regions. In collaboration
with the 88 acute care hospitals in the Com-
monwealth, six hospital and healthcare plan-
ning regions were established, closely corre-
sponding with five health department planning
regions. Each of the six hospital planning
regions has a designated Regional Hospital
Coordinating Center (RHCC) located at or near
the Level I trauma facility in the region as well
as a regional hospital coordinator funded
through the HRSA cooperative agreement.
Near Southwest Preparedness Alliance
The Near Southwest Preparedness Alliance
(NSPA), which covers the Virginia Tech area,
was developed under the auspices of the West-
ern Virginia EMS Council pursuant to a memo-
randum of understanding between the Virginia
Department of Health, the Virginia Hospital
and Healthcare Association, and the NSPA.
NSPA is organized to facilitate the development
of a regional healthcare emergency response
system and to support the development of a
statewide healthcare emergency response sys-
tem. Regional hospital preparedness and coor-
dination will foster collaborative planning
efforts between the several medical care facili-
ties and local emergency response agencies in
the established geographically and demographi-
cally diverse region.
75

The Near Southwest region is defined as:
4th Planning District (New River area),
which includes Floyd, Giles, Montgom-
ery, and Pulaski counties and the City of
Radford.
5th Planning District (Roanoke and
Alleghany area), which includes
Alleghany, Botetourt, Craig, and Roa-
noke counties as well as the cities of
Covington, Roanoke, and Salem.
11th Planning District, which includes
Amherst, Appomattox, Bedford, and

75
Ibid.
M
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
117
Campbell counties; the cities of
Lynchburg and Bedford; and the towns
of Altavista, Amherst, Appomattox, and
Brookneal.
12th Planning District (Piedmont area),
which includes Franklin, Henry, Patrick
and Pittsylvania counties and the cities
of Danville and Martinsville
The region covers 7,798 square miles and
houses a population of 910,900. It has 24 local
governments and 16 hospitals.
Regional Hospital Coordinating Center
At the regional level, hospital emergency
response coordination during exercises and
actual events is provided by RHCCs that have
been established to facilitate emergency
response, communication, and resource alloca-
tion within and among each of the six hospital
regions. These centers serve as the contact
among healthcare facilities within the region
and with RHCCs in other state regions. RHCCs
are also linked to the statewide response system
through the hospital representative seat at the
VDH Emergency Coordinating Center (ECC) in
Richmond, Virginia. The hospital seat at the
ECC serves as the contact between the health-
care provider system and the statewide emer-
gency response system. It provides a communi-
cation link to the Virginia Emergency Opera-
tions Center (VEOC).
76

The primary responsibilities of the RHCC
include:
Provide a single point of contact between
hospitals in the region and the VDH
ECC.
Collect and disseminate initial event no-
tification to hospitals and public safety
partners.
Collect and disseminate ongoing situ-
ational awareness updates and warn-
ings, including the management of the
current bed availability in hospitals.

76
Ibid.
Establish and manage WebEOC
77
and
communications systems for the dura-
tion of the incident.
Serve as the single point of contact and
collaboration point for Virginia fire/EMS
agencies for the purposes of hospital di-
version management, movement of
patients from an incident scene to
receiving hospitals, and input/guidance
with respect to hospital capabilities,
available services, and medical trans-
port decisions.
Coordinate interhospital patient move-
ment, transfers, and tracking
Provide primary resource management
to hospitals for:
Personnel
Equipment
Supplies
Pharmaceuticals.
Coordinate regional expenditures for
reimbursement.
Coordinate regional medical treatment
and infection control protocols during
the incident as needed.
Coordinate Virginia hospital requests
for the Strategic National Stockpile
through the local jurisdiction EOC.
The RHCC complements but does not replace
the relationships and coordinating channels
established between individual healthcare
facilities and their local emergency operations
centers and health department officials. The
regional structure is intended to enhance the
communication and coordination of specific
issues related to the healthcare component of
the emergency response system at both regional
and state levels.
At 10:05 a.m. on April 16, MRH requested that
the RHCC be activated. At 10:19 a.m., it was
activated under a standby status and signed on

77
WebEOC is a web-based information management system
that provides a single access point for the collection and
dissemination of emergency or event-related information
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
118
to WebEOC.
78
By 10:25 a.m., the Virginia De-
partment of Health also had signed on to
WebEOC and monitored the event. At 10:40
a.m., the RHCC requested that all hospitals
provide an update of bed status and diversion
status for their facility. By 10:49 a.m., LGMC
was the only hospital that signed on to WebEOC
of the hospitals that had received patients from
the Norris Hall incident. Pulaski County Hospi-
tal also signed on and provided their status. At
11:49 a.m. (1 hour later), MRH signed on fol-
lowed by CNRVH at 12:33 p.m.
79

The WebEOC boards (the RHCC Events Board
and the Near Southwest Region Events Board)
were used for a variety of communications
between the RHCC, hospitals, and other state
agencies. Some hospitals spent considerable
time attempting to post information on the
WebEOC boards. None of the EMS jurisdictions
signed on to either of the boards. Not all hospi-
tals or EMS agencies are confident in using
WebEOC and require regular training drills for
familiarity.
The hospitals and public safety agencies should
have used the RHCC and WebEOC expedi-
tiously to gain better control of the situation.
Considering the many rumors and unconfirmed
reports concerning patient surge, the incident
could have been better coordinated. If the RHCC
was kept informed as per the MCI plan, it could
have acted as the one official voice for informa-
tion concerning patient status and hospital
availability.
Western Virginia EMS Mass Casualty
Incident Plan The Western Virginia EMS
region encompasses the 7 cities and 12 counties
of Virginia Planning Districts 4, 5, and 12. The
region extends from the West Virginia border to
the north and to the North Carolina border to
the south. The region encompasses the urban
and suburban areas of Roanoke and Danville, as

78
Baker, B. (2007). VA Tech 4-16-2007: RHCC Events
Board, p. 1.
79
Baker, B. (2007). April 16, 2007: Near Southwest Region
Events Board, p. 1.
well as many rural and remote areas such as
those in Patrick, Floyd, and Giles counties. The
regions total population (based on 1998 esti-
mates) is 661,200. The region encompasses
9,643 square miles.
The region encompasses the counties of
Alleghany, Botetourt, Craig, Floyd, Franklin,
Giles, Henry, Montgomery, Patrick, Pittsylva-
nia, Pulaski, and Roanoke (Figure 21).
80

Figure 21. Map Showing Counties in the
Western Virginia EMS Region
81

Multicasualty Incidents The Western
Virginia EMS Mass Casualty Incident Plan
(WVEMS MCI) plan defines a multiple casualty
incident as an event resulting from man-made
or natural causes which results in illness and/or
injuries that exceed the emergency medical ser-
vices capabilities of a hospital, locality, jurisdic-
tion and/or region.
82
Online medical direction is
the responsibility of the MCI Medical Control,
defined as:
That medical facility, designated by the
hospital community, which provides remote
overall medical direction of the MCI or
evacuation scene according to predeter-
mined guidelines for the distribution of
patients throughout the community.
83


80
WVEMS. (2006). Trauma Triage Plan. Western Virginia
EMS Council, Appendix E.
81
Ibid.
82
WVEMS. (2006). Mass Casualty Incident Plan: EMS
Mutual Aid Response Guide: Western Virginia EMS Council,
Section 2.1.1, p. 1.
83
Ibid., Section 2.1.4, p. 1.
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
119
Access to online physician medical direction
should be available. In MCI situations, modern
EMS systems rely more on standing orders and
protocols and less on online medical direction.
Therefore, it may be more logical to have the
RHCC coordinate these efforts, including patch-
ing in providers to online physician medical
direction as needed.
The MCI plan identifies three levels of incidents
based on the initial EMS assessment using the
Virginia START Triage System:
Level 1 Multiple-casualty situation
resulting in less than 10 surviving vic-
tims.
Level 2 Multiple casualty situation
resulting in 10 to 25 surviving victims.
Level 3 Mass casualty situation result-
ing in more than 25 surviving victims.
84

The Virginia Tech incident clearly fits into the
definition of a Level 3 MCI, since at least 27
patients were treated in local emergency
departments.
Frustrating communications issues and barriers
occurred during the incident. Every service
operated on different radio frequencies making
dispatch, interagency, and medical communica-
tions difficult. These issues included both on-
scene and in-hospital situations that could be
avoided. Specific communications challenges
included the following:
The radios used by responding agencies
consisted of VHF, UHF, and HEAR fre-
quencies. This led to on-scene communi-
cations difficulties and the inability for
EMS command or Virginia Tech dis-
patch to assure that all units were
aware of important information.
Communications between the scene and
the hospitals were too infrequent. Hos-
pitals were unable to understand exactly
what was going on at the scene. They

84
Ibid., Section 7, p. 4.
were unable to determine the appropri-
ate level of preparation.
In several instances, on-scene providers
called hospitals or other resources
directly instead of through the ICS. This
included relaying incorrect information
to hospitals.
Cell phones and blackberries worked
intermittently and could not be relied
upon. Officials did not have time to
return or retrieve messages left on cell
phones. A mobile cell phone emergency
operating system was not immediately
available to EMS providers.
Interviews with EMS and hospital personnel
reiterated a well-known fact: face-to-face com-
munications, when practical, is the preferred
method.
From a technological standpoint, the NIMS
requirement for interoperability is critical. Local
communities must settle historical issues and
move forward toward an efficient communica-
tions system.
Lack of a common communications system
between on-scene agencies creates confusion
and could have caused major safety issues for
responders. Each jurisdiction having its own
frequencies, radio types, dispatch centers, and
procedures is a sobering example of the lack of
economies of scale for emergency services. Local
political entities must get past their inability to
reach consensus and assure interoperability of
their communications systems. In this case, the
most reasonable and prudent action probably
would be to expand the Montgomery County
Communications System to handle all public
safety communications within the county. Coop-
eration, consensus building, and the provision of
adequate finances are required by emergency
service leaders and governmental entities. Fail-
ure to accomplish this goal will leave the region
vulnerable to a similar situation in the future
with potentially tragic results.
Unified Command There is little evidence
that there was a unified command structure at
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
120
the Virginia Tech incident. Command posts
were established for EMS and law enforcement
at the Norris Hall scene and for law enforce-
ment at another location. Separate command
structures are traditional for public safety agen-
cies. The 9/11 attack in New York City exempli-
fied the need for public safety agencies to step
back and reconsider these traditions. At Norris
Hall, a unified command structure could have
led to less confusion, better use of resources,
better direction of personnel, and a safer work-
ing environment. Figure 22 depicts a proposed
model unified command structure that could
have been utilized.
The unified command post would be staffed by
those having statutory authority. During the
Virginia Tech incident, those personnel would
likely have been the police chiefs for VTPD and
the BPD, a university official, a VT EMS officer,
a BVRS EMS officer, the FBI special agent-in-
charge, the state police superintendent, and the
ranking elected official for the City of Blacks-
burg. The operations section chief would have
received operational guidelines from the unified
command post and assured their implementa-
tion.
The unified command team would be in direct
communications with the EOC and policymak-
ing group. Command and general staff members
would have communicated with their counter-
parts in the EOC. The policymaking group
would have transmitted their requests to the
EOC and the unified command post.

*For this incident, law enforcement would have been the lead agency. The unified command post would be staffed by
those having statutory authority. During the Virginia Tech Incident, those personnel would likely have been the police
chiefs for the VTPD and BPD, a university official, a VT EMS officer, the FBI special agent-in-charge, the Virginia State
Police superintendent, and the ranking elected official for the City of Blacksburg.
Figure 22. Proposed Model Unified Command Structure for an April 16-Like Incident

Unified
Command*
Safety Officer
EMS or Fire
Liaison Officer
Montgomery County
Emergency Coord.
PIO
J oint Information
Center
Planning
Section Chief
VT Police or VTRS
Finance/
Administration
Virginia Tech Univ.
Logistics
Section Chief
Virginia Tech EMS
Operations
Section Chief
Virginia Tech or
Blacksburg Police
Law
Enforcement
Branch
EMS
Branch
Deputy Planning
Section Chief
FBI or ATF Assistant
Special Agent In
Charge (ASAIC)
Unified
Command*
Safety Officer
EMS or Fire
Liaison Officer
Montgomery County
Emergency Coord.
PIO
J oint Information
Center
Planning
Section Chief
VT Police or VTRS
Finance/
Administration
Virginia Tech Univ.
Logistics
Section Chief
Virginia Tech EMS
Operations
Section Chief
Virginia Tech or
Blacksburg Police
Law
Enforcement
Branch
EMS
Branch
Deputy Planning
Section Chief
FBI or ATF Assistant
Special Agent In
Charge (ASAIC)

121
Emergency Operations Center The lack
of an EOC activated quickly as the incident un-
folded led to much of the confusion experienced
by hospitals and other resources within the
community. An EOC should have been activated
at Virginia Tech. The EOC is usually located at
a pre-designated site that can be quickly acti-
vated. Its main goals are to support emergency
responders and ensure the continuation of
operations within the community. The EOC
does not become the incident commander but
instead concentrates on assuring that necessary
resources are available.
A policy-making group would function within
the EOC. Virginia Tech had assembled a policy
making group that functioned during the inci-
dent.
Another responsibility of the EOC is the estab-
lishment of a joint information center (JIC) that
acts as the official voice for the situation at
hand. The JIC would coordinate the release of
all public information and the flow of informa-
tion concerning the deceased, the survivors,
locations of the sick and injured, and informa-
tion for families of those displaced. By not im-
mediately activating an EOC, hospitals or the
RHCC did not receive appropriate or timely
information and intelligence. There was also a
delay in coordinating services for families and
friends of victims who needed to be identified or
located. Although Virginia Tech eventually set
up a family assistance center, it was not done
immediately.
KEY FINDINGS
Positive Lessons
The EMS responses to the West Ambler Johns-
ton residence hall and Norris Hall occurred in a
timely manner.
Initial triage by the two tactical medics accom-
panying the police was appropriate in identify-
ing patient viability.
The application of a tourniquet to control a
severe femoral artery bleed was likely a life-
saving event.
Patients were correctly triaged and transported
to appropriate medical facilities.
The incident was managed in a safe manner,
with no rescuer injuries reported.
Local hospitals were ready for the patient surge
and employed their NIMS ICS plans and man-
aged patients well.
All of the patients who were alive after the
Norris Hall shooting survived through discharge
from the hospitals.
Quick assessment by a hospitalist of emergency
department patients waiting for disposition
helped with preparedness and patient flow at
one hospital.
The overall EMS response was excellent, and
the lives of many were saved.
EMS agencies demonstrated an exceptional
working relationship, likely an outcome of
interagency training and drills.
Areas for Improvement
All EMS units were initially dispatched by the
Montgomery County Communications Center to
respond to the scene; this was contrary to the
request.
There was a 4-minute delay between VTRS
monitoring the incident (9:42 a.m.) on the police
radio and its being dispatched by police (9:46
a.m.).
Virginia Tech police and the Montgomery
County Communications Center issued separate
dispatches. This can lead to confusion in an
EMS response.
BVRS was initially unaware that VTRS had
already set up an EMS command post. This
could have caused a duplication of efforts and
further organizational challenges. Participants
interviewed noted that once a BVRS officer
reported to the EMS command post, communi-
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
122
cations between EMS providers on the scene
improved.
Because BVRS and VTRS are on separate pri-
mary radio frequencies, BVRS reportedly did
not know where to stage their units. In addition,
BVRS units were reportedly unaware of when
the police cleared the building for entry.
Standard triage tags were used on some
patients but not on all. The tags are part of the
Western Virginia EMS Trauma Triage Protocol.
Their use could have assisted the hospitals with
patient tracking and record management. Some
patients were identified by room number in the
emergency department and their records
became difficult to track.
The police order to transport the deceased under
emergency conditions from Norris Hall to the
medical examiners office in Roanoke was
inappropriate.
The lack of a local EOC and fully functioning
RHCC may lead to communications and opera-
tional issues such as hospital liaisons being sent
to the scene. If each hospital sent a liaison to
the scene, the command post would have been
overcrowded.
A unified command post should have been
established and operated based on the NIMS
ICS model.
Failure to open an EOC immediately led to
communications and coordination issues during
the incident.
Communications issues and barriers appeared
to be frustrating during the incident.
RECOMMENDATIONS
IX-1 Montgomery County, VA should
develop a countywide emergency medical
services, fire, and law enforcement commu-
nications center to address the issues of
interoperability and economies of scale.
IX-2 A unified command post should be
established and operated based on the
National Incident Management System
Incident Command System model. For this
incident, law enforcement would have been the
lead agency.
IX-3 Emergency personnel should use the
National Incident Management System
procedures for nomenclature, resource typ-
ing and utilization, communications,
interoperability, and unified command.
IX-4 An emergency operations center must
be activated early during a mass casualty
incident.
IX-5 Regional disaster drills should be held
on an annual basis. The drills should include
hospitals, the Regional Hospital Coordinating
Center, all appropriate public safety and state
agencies, and the medical examiners
office. They should be followed by a formal post-
incident evaluation.
IX-6 To improve multi-casualty incident
management, the Western Virginia Emer-
gency Medical Services Council should
review/revise the Multi-Casualty Incident
Medical Control and the Regional Hospital
Coordinating Center functions.
IX-7 Triage tags, patient care reports, or
standardized Incident Command System
forms must be completed accurately and
retained after a multi-casualty incident.
They are instrumental in evaluating each com-
ponent of a multi-casualty incident.
IX-8 Hospitalists, when available, should
assist with emergency department patient
dispositions in preparing for a multi-
casualty incident patient surge.
IX-9 Under no circumstances should the
deceased be transported under emergency
conditions. It benefits no one and increases the
likelihood of hurting others.
IX-10 Critical incident stress management
and psychological services should continue
to be available to EMS providers as needed.
CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE
122 - A
ADDITIONS AND CORRECTIONS
(No changes from original report.)
COMMENT
One family member noted that the Report states that at 10:51 a.m. all patients from Norris
Hall had either been transported to the hospital or to a minor treatment area and that at 11:40
a.m. Montgomery Regional Hospital received the last patient. The question was why it took 49
minutes to transport the last gunshot victim to the hospital.
Response: As noted in the Report, Norris Hall patients were triaged at the scene using the
Simple Triage and Rapid Treatment system. The most seriously injured victims, who were de-
noted with a red tag as requiring immediate treatment, were transported to the hospital first.
Those whose injuries were less severe (yellow tag) were attended to first at the delayed treat-
ment unit set up at Stanger and Barger Streets and then transported to a hospital shortly af-
terward. This is standard, acceptable practice during a mass casualty incident. The overall
EMS process received high marks from the professor of emergency medicine on the panel, and
the staff member who is an instructor at the National Fire Academy on EMS management.

(This page intentionally left blank.)

123
Chapter X.
OFFICE OF THE CHIEF MEDICAL EXAMINER
n April 16, 2007, after the gunfire ceased on
the Virginia Tech campus and the living
had been triaged, treated, and transported, the
sad job of identifying the deceased and conduct-
ing autopsies began. Since these were deaths
associated with a crime, autopsies were legally
required. The Office of the Chief Medical Exam-
iner (OCME) had to scientifically identify each
victim and conduct autopsies to determine with
specificity the manner and cause of death. Au-
topsy reports help link the victim to the perpe-
trator and to a particular weapon. The OCME
also has a role in providing information to vic-
tims families.
To assess how these responsibilities were met,
the panel interviewed:
The parents and family members of the
deceased victims
Dr. Marcella F. Fierro, Chief Medical
Examiner and her staff
Colonel Steven Flaherty, Superinten-
dent of Virginia State Police
Mandie Patterson, Chief of the Victim
Service Section, Virginia Department of
Criminal Justice Services
Jill Roark, Terrorism and Special Juris-
diction, Victim Assistance Coordinator,
Federal Bureau of Investigation
Mary Ware, Director of the Criminal
Injuries Compensation Fund
Numerous victim service providers.
The panel also reviewed the report issued by the
OCME on areas for improvement, lessons
learned, and recommendations.
LEGAL MANDATES AND STANDARDS
OF CARE
he Office of the Chief Medical Examiner
incorporates a statewide system with head-
quarters in Richmond and regional offices in
Fairfax, Norfolk, and Roanoke. Commonwealth
law requires the OCME to be notified and to
investigate deaths from violence.
85

Autopsies are used to collect and document evi-
dence to link the accused with the victim of the
crime. In the Virginia Tech cases, this was bal-
listic evidencebullets and fragments of bullets.
The autopsies provided scientific evidence on
the types and numbers of bullets that caused
the fatal injuries.
The OCME also must ensure that there is com-
plete, accurate identification of the human
remains presented for examination. When there
are multiple fatalities, the possibility exists that
there could be a misidentification, which would
result in the release of the wrong body to at
least two families. Though a rare occurrence,
there are examples of this type of error in recent
history. The National Association of Medical
Examiners (NAME) has adopted Forensic
Autopsy Performance Standards, which are con-
sidered minimal consensus standards. The most
recent version was approved in October 2006.
Dr. Fierro is a member of the standards commit-
tee of NAME.
The NAME standards require several proce-
dures to be performed if human remains are
presented that are unidentified. A major issue
with some of the families of those who were
murdered, however, was that they felt they were
capable of identifying the body of their family
member; in other words, from their viewpoint,
the remains were not unidentifiable.

85
Sec. 32.1-283 Investigations of deaths. Section A, Code
1950
O
T
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
124
Family members of homicide victims are gener-
ally unaware that the medical examiner is
required to complete a thorough, scientific
investigation in order to identify a body, deter-
mine the cause of death, and collect evidence.
For the family members of victims, the experi-
ence is focused on immediacy. Is my loved one
dead? When can I see my loved one? As hap-
pened at Virginia Tech, a difference in perspec-
tives can cause deep hurt and misunderstand-
ing. A separate matter in some of the cases was
whether it was advisable for a family to view
the remains.
The Virginia Tech incident presented the poten-
tial for misidentification. Bodies were presented
with either inconsistent identification or none at
all. This is not uncommon in mass fatality
scenes due to the amount of confusion that gen-
erally exists. In order to prevent misidentifica-
tion, medical examiners have established a rig-
orous set of practices based on national stan-
dards to ensure that identification is irrefutable.
The Virginia OCME followed these standards as
well as Commonwealth law in identifying the
deceased.
DEATH NOTIFICATION
he death notification process is the opening
portal to the long road of painful experi-
ences and varying reactions that follow in the
wake of the life-altering news that a loved one
has met with death due to homicide. This news
that someone intentionally murdered a family
member is the critical point of trauma and often
inflicts its own wounds to the body, mind, and
spirit of the survivors. From a psychological and
mental health perspective, trauma is an emo-
tional wounding that affects the will to live and
ones beliefs, assumptions, and values.
A homicide affects victims families differently
than other crimes due to its high-profile nature,
intent, and other factors. The act of informing
family members of a homicidal death requires a
responsible, well-trained, and sensitive individ-
ual who can manage to cope with this mutually
traumatizing experience. Family members of
deceased victims have a wide range of needs and
reactions to the sudden and untimely death of
their loved ones. Consequently, the individuals
who deliver the death notifications and the
manner in which they carry out this duty factor
significantly in the trauma experienced by the
family. Death notifications must be delivered
with accuracy, sensitivity, and respect for the
deceased and their families. Ideally, death noti-
fication should be delivered in private, in per-
son, and in keeping with a specific protocol
adopted from one of the effective models.
EVENTS
Monday, April 16 The closest OCME office
to Virginia Tech is located in Roanoke. All re-
mains from the western part of the common-
wealth that require an autopsy are taken there.
In
addition to their full-time employees, the OCME
has part-time and per-diem investigators to help
conduct death investigations and refer cases to
the regional offices.
The first news about the Virginia Tech shoot-
ings came to the OCME from the Blacksburg
Police Department at 7:30 a.m. A police evi-
dence technician there, who also is a per-diem
employee for the ME, called to say he would not
be able to attend a scheduled postmortem exam
(autopsy) because there had been a shooting at
the Virginia Tech campus. At this time, six
cases were awaiting examination in the western
regional office, an average caseload.
By 11:30 a.m., another per-diem medical exam-
iner, who was a member of a local rescue squad,
notified the regional OCME office of a multiple
fatality incident at Norris Hall with upwards of
50 victims. It was at this time that one of the
decedents from West Ambler Johnston (WAJ)
residence hall was transported to Carillion
Roanoke Memorial Hospital. The western office
notified the central office in Richmond that
additional assistance would be needed to handle
the surge in caseload.
At 1:30 p.m., representatives from the Roanoke
office arrived on campus and attended an inci-
dent management team meeting with the public
T
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
125
safety agencies that had responded. OCME rep-
resentatives attended the operations section
briefing. The activities in Norris Hall were
organized by areas (classrooms and a stairway).
Investigation teams of law enforcement and
OCME employees were assigned specific tasks.
The OCME requested resources from the north-
ern regional office in Fairfax and the central
office in Richmond. They, along with Dr. Fierro,
departed for Blacksburg by 3:00 p.m. The west-
ern office had two vacancies in forensic patholo-
gist positions, so additional staff clearly was
needed.
The first autopsy that of one of the dormitory
victims, began at 3:15 p.m. No autopsy could
begin until after the crime scene had been thor-
oughly documented and investigated. As each
decedent was transported from campus, the
Roanoke regional office was notified so that a
case number could be assigned.
By 5:00 p.m., the first victim from Norris Hall
had been transported to the Roanoke office.
Volunteer rescue squads were transporting the
victims from campus to the regional office, a 45-
minute trip.
At 6:30 p.m., Dr. Fierro and additional staff
from Richmond arrived and met with represen-
tatives from state police and the Departments of
Health and Emergency Management. The
methods for identification were discussed, as
was the process of documenting personal effects.
The last victim was removed from Norris Hall
and transported to Roanoke by 8:45 p.m. By
11:30 p.m., the first autopsy was completed;
identification made, next of kin notified, and the
remains released to a funeral home.
Tuesday, April 17 In the early morning
hours of the first day after the shooting, addi-
tional pathologists departed the Tidewater and
central regional offices for Roanoke. A staff
meeting was held at 7:00 a.m. to formulate the
OCME portion of the incident action plan (IAP).
Key points addressed for the morgue operations
sections included:
All victims were to be forensically
identified prior to release.
A second-shooter theory was still under
consideration by law enforcement. As
such, all ballistic evidence had to be col-
lected and documented. The distribution
of gunshot wounds was:
One victim with nine
One victim with seven
Five victims with six
One victim with five
Five victims with four
The remainder of the victims had three or fewer
gunshot wounds. The complexity of tracking
bullet trajectories and retrieving fragments
would be especially time consuming for the mul-
tiple wounds.
It was decided to use fingerprints as the pri-
mary identification method and dental records
as the secondary. The reasons for this decision
were:
Fingerprints were able to be taken from
all of the victims.
Foreign students had prints on file with
Customs and Border Protection.
There was an abundance of latent prints
on personal effects in dorm rooms and
apartments and on personal effects
recovered on site.
The Department of Forensic Services
had adequate staff available to assist in
the collection and comparison of the fin-
gerprints. (The police reported that
nearly 100 law enforcement officers from
local, state, and federal agencies volun-
teered or were assigned to assist in
gathering prints and other identifica-
tion.)
The alternative method for identification, dental
examination, required the name of the dece-
dents dentist to obtain dental records, and
families were asked to provide the contact
information in case that method was needed.
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
126
DNA was excluded as a means of identification
because the collection and processing of samples
would have taken weeks.
In addition to being short-staffed by two vacan-
cies and one injured pathologist, the MEs office
had to respond to the concerns and demands of a
religious group that contested one of the autop-
sies. By the end of the first day of operations, all
of the deceased, 33, had been transported to the
western region office. Thirteen postmortem ex-
aminations had been completed, two positive
identifications had been made, and two families
were notified and the remains released and
picked up by next of kin or their representative.
Wednesday, April 18 On the second day of
morgue operations, the process of forensic iden-
tification continued. Procedures began at 7:45
a.m. and continued until 8:00 p.m.
At 10:00 a.m., the chief medical examiner gave a
press conference where she discussed forensic
procedures and the methods employed.
At 11:00 a.m., a representative from OCME
assisted in collecting antemortem data from the
families who had gathered at the family assis-
tance center at The Inn at Virginia Tech.
VIP AND MISUNDERSTANDINGS: The primary form
OCME uses to collect antemortem data is called
a Victim Identification Protocol (VIP) form. This
form, used by many medical examiners and fed-
eral response teams, documents information on
hair and eye color, medical history (such as an
appendectomy), and other distinguishing marks
such as scars or tattoos. During a postmortem
examination, the pathologist conducting the au-
topsy comments on his or her findings and each
identifier and that information is entered into a
case file. Forensic odontology (dental) and
fingerprint findings may also be incorporated.
Both profiles can be compared electronically and
possible matches or exclusions made. The
pathologist then reviews these findings as part
of the scientific identification.
As case files were compiled, a designation was
made as to whether a VIP form was available
and included in the file. Some state officials,
seeing the VIP acronym, mistakenly concluded
that OCME had designated some victims as
VIPs (very important persons), singling them
out for special consideration. As it happened,
several embassies did contact state officials to
demand preferential treatment for their nation-
als who were among the victims. However, the
OCME did not provide any preferential or VIP
treatment.
MEDIA MISINFORMATION: Radio station K-92
announced that the coroner would be releasing
all of the human remains on Wednesday, April
18. The origin of this incorrect report is
unknown.
TRACKING INFORMATION: At the request of the gov-
ernors office, a spreadsheet that detailed spe-
cific information for each victim was developed.
During this process, members of the governors
staff became concerned that the OCME had pri-
oritized some cases. But in fact, cases were han-
dled without a specific plan or intent to priori-
tize them.
Staff members from the OCME went to the Inn
to assist in the operation of the FAC. The
Virginia State Police and the OCME established
a process and team to notify families that their
loved ones had been positively identified.
IDENTIFICATION AND VIEWING: Family members of
the deceased victims were anxious for the for-
mal identification and release of the bodies to be
completed. In response to the concerns of family
members regarding the length of time involved
in the identification process, some state officials
suggested that the families should be permitted
to go to the morgue and identify the bodies if
they so chose. Though this would seem reason-
able, it conflicts with current practice.
A public information officer at the FAC
explained to families who were assembled there
what the OCME policy was regarding visible
presumptive identification. Then the public
information officer (PIO) unfortunately asked
the families for a show of hands of those who
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
127
wanted to view the remains of their loved ones
in case that could be arranged.
Viewing and identifying remains is a significant
issue for victim survivors. Even though identifi-
cation of the body by family members is not
always considered scientifically reliable, for
various reasons, victim survivors often want to
make that decision for themselves. At Virginia
Tech, families were frustrated with the lack of
information from OCME and why it was taking
so long to identify and release the victims
remains. Medical examiners must be sensitive
to the waiting family members need to be kept
informed when there are delays and when they
can expect a status update
The remains of persons killed in a crime become
part of the evidence of the crime scene, and are
legally under the jurisdiction of the OCME until
released. The OCME can set the conditions it
thinks are appropriate for the situation. The
standard of care does not include presumptive
identification using visual means. The public
information officer who asked for a show of
hands should not have done so.
When the protocol and policies of the OCME
were explained to the families, some of the ten-
sion seemed to abate. The confusion and misun-
derstanding surrounding these issues involved
misinformation, late information, no informa-
tion, and the high emotional stress of the event.
Had a public information officer with a back-
ground in the operations of the OCME been
available or a representative from the OCME
been present to answer these concerns, the con-
troversy regarding this issue could have been
reduced or eliminated.
IDENTIFICATION PROGRESS: The progress of the first
day continued on the second day of morgue
operations. The second-shooter theory had been
discounted after it was determined forensically
that Cho used two different weapons. By the
end of the second day, another 20 autopsies had
been completed, which meant that all 33 victims
had received a postmortem exam. At this point,
there were 22 total identifications and 22
remains released to next of kin. Morgue opera-
tions were conducted from 7:00 a.m. to 8:00 p.m.
Thursday, April 19 The third day of morgue
operations began at 7:00 a.m. It was determined
that the OCME would work around the clock if
necessary to complete the identification process
this day. By this time, all of the antemortem
records had arrived at the regional office.
The media had gathered in the area of the
morgue and was covering the activities of repre-
sentatives of the familiesusually funeral
homesas they arrived to pick up the remains.
Roanoke County law enforcement provided
security.
All of the remaining decedents were identified
and released by 6:00 p.m. The last case was a
special challenge as there were no fingerprints
on file and the victim did not have a dentist of
record. The latent prints in the home were not
readable. The identification was completed
through a process of exclusion and definition of
unique physical properties using the Victim
Identification Protocol process. The Virginia
OCME had completed 33 postmortem exams
and correctly made 33 positive legal identifica-
tions within 3 working days.
Figure 23 summarizes the statistics for 3-day
morgue operations. The figure shows that not
all of the remains were picked up by the end of
morgue operations because Chos family did not
pick up his remains for several days after the
operations were shut down.
ISSUES
hree major issues surfaced during panel
interviews and the collection of after-action
reports in regards to the actions of the Virginia
OCME; these were primarily issues presented
by some families of the deceased:
Some felt the autopsy process took too
long.
Some felt families should have been
allowed to go to the morgue and visibly
identify their family members.
T
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
128
Figure 23. Progress and Activity of the OCME Over the 3-Day Period April 1719, 2007
Many felt the process of notifying the
families and providing assistance to the
families was disjointed, unorganized,
and in several cases insensitive.
Speed There is no nationally accepted time
standard for the performance of an autopsy. The
NAME standards mentioned earlier do not set
time standards.
The average duration of the postmortem exams
was just under 2 hours. Had the OCME office
been fully staffed, it may have been able to per-
form the identifications and examinations
somewhat more rapidly. The OCME did have a
disaster plan that it implemented upon notifica-
tion of the events. The plan called for staff from
the regional and central offices to deploy to the
regional office where the disaster occurred to
meet the surge in caseload, which was done.
The OCME did not call for federal assistance,
which is available from the Department of
Health and Human Services National Disaster
Medical System (NDMS) program. That pro-
gram can deploy a disaster mortuary opera-
tional response team (DMORT) composed of fo-
rensic specialists who can assist medical exam-
iners in the event of mass fatality incidents. The
DMORT system has three portable morgue
units. DMORT resources (in this case, just per-
sonnel) could have been requested and probably
been in place within 24 hours of mobilization.
86

For example, a DMORT was used in the Station
Nightclub fire in Rhode Island in February 2003
to assist the Rhode Island medical examiner in
the identification of the victims of that fire.
Once antemortem information had been gath-
ered, DMORT personnel could have worked a
second shift and might have reduced the elapsed
time of morgue operations by 24 hours. Given
the information regarding the performance of

86
A member of TriDatas support staff to the panel is a
member of a DMORT and provided first-hand information
on its operation.

2
2
4
1
2
4
13
10
21
21
1
1
19
19
20
19
10
9
1
4
4
8
0 5 10 15 20 25 30 35 40
Picked Up
Released
Total IDs
Other IDs
Dental IDs
IDby Prints
AnteRecords
Autopsies
Day One
Day Two
Day Three
Source: Virginia Office of the Medical Examiner'
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
129
the family assistance center, which also was the
responsibility of OCME, this early collection
may or may not have occurred. The time delay
for identifications came from delays in gathering
antemortem information and then providing
that information to the OCME, a task outside
the control of the OCME.
Identification and Viewing The second
issue was the insistence by the OCME to per-
form forensic identifications of the victims as
opposed to presumptive identifications. Forensic
identifications use methods such as fingerprint-
ing, dental records, DNA matches, or other sci-
entific means for identification. Presumptive
identification includes photographs, drivers
licenses, and visual recognition by family or
friends.
Some of the families wanted to go to the
regional office of the OCME to view the remains
and identify the victims. The OCME did not
permit this for several reasons. For one, the
regional office does not have an area large
enough to display all the bodies for families to
view each one to determine whether it is their
family member
As noted earlier, the idea of families viewing
their loved one and making a legally binding
identification is not the current practice of the
OCME because it is not considered scientifically
reliable. Nevertheless, it was emotionally
wrenching for families not to have a choice in
this matter. Presumptive identification is
acceptable in some communities under certain
conditions. OCME noted that several female
victims had no personal effects such as a
drivers license or student identity card when
they were transported to the hospital or morgue.
At the same time, some families told the medi-
cal examiners office about specific moles, scars,
or other distinguishing marks that were far
more reliable than a purse and could not be con-
fused with another victim.
A textbook for students of forensic pathology
discusses the identification of human remains.
Regarding the topic of reliable visual identifica-
tion:
The operative word in this method of iden-
tification is reliable [italics added]. Per-
sonal recognition of visage or habitus,
under certain circumstances, is less reli-
able than fingerprints, dental data, or
radiology. It (this method) relies on mem-
ory and a rapid mental comparison of
physical features under stressful conditions
and often a damaged body.
Another hazard in visual identification is
denial. The situation may be so stressful or
the remains altered by age, injury, disease
or changes in lifestyle that identification is
denied even if later confirmed by finger-
prints or dental examination.
87

In Clinics in Laboratory Medicine, Victor Weedn
writes:
Visual recognition is among the least reli-
able forms of identification. Even brothers,
sisters and mates have misidentified vic-
tims. Family members may find it emo-
tionally difficult and uncomfortable to care-
fully gaze at the dead body, particularly a
loved one. Identification requires a rapid
mental comparison under stressful condi-
tions. The environment in which the identi-
fication is made and the appearance of the
person at death are unnatural and
strange.
88

Family Treatment The third issue was the
treatment of the families of the decedents
regarding official notification and support while
waiting for positive identification. Their treat-
ment was haphazard, inconsistent, and com-
pounded the pain and trauma of the event.
Victims of crime are afforded a number of
rights, among them the right to be treated with
dignity and respect. The right of respect speaks
to victims being given honest and direct infor-
mation free of any attempt to protect them from
perceived emotional injury or their inability to
process information. Crime victims rights are
protected by federal and state laws. Basic rights

87
Spitz and Fisher, Medicolegal Investigation of Death, 3rd
edition, Edited by Werner U. Spitz. 1993, pages 7778.
88
Victor Weedn, Postmortem Identification of Remains,
Clinics in Laboratory Medicine, Volume 18, March 1998,
page 117.
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
130
for victim survivors generally include the right
to be notified and heard, and to be informed.
In 1996, following several airline accidents, the
families of the victims felt the airline companies
and government officials did not address their
needs, desires, or expectations. In that year,
Congress passed the Aviation Disaster Family
Assistance Act. This law holds airline compa-
nies and government officials, such as medical
examiners and coroners, accountable to the
National Transportation Safety Board for com-
passionate, considerate, and timely information
regarding the disposition of their loved ones or
next of kin.
The U.S. Department of Justice, through its
Office of Justice Programs, has an Office for
Victims of Crime (OVC) that can provide
support for victims of federal crimes such as
terrorism.
To this end, many medical examiners offices
have developed plans for the establishment of
family assistance centers. A FAC serves several
purposes. First, it is the location where families
can receive timely, accurate, and compassionate
information from officials. Second, medical
examiners office staff can collect vital ante-
mortem information from families there to
assist in the positive identification of the
deceased. Third, it can be the location where
private, compassionate notification of the posi-
tive identification of the deceased can be con-
ducted with next of kin.
A FAC was established in Oklahoma City in
April 1995 following the Murrah Building bomb-
ing. Families were notified in private, before the
media was notified. This model for the compas-
sionate, accurate information exchange was
published by the federal OVC.
89

Although a FAC was established at The Inn at
Virginia Tech, reports received by the panel
indicate that what was provided was not

89
OVC, Providing Relief After a Mass Fatality, Role of the
Medical Examiners Office and the Family Assistance Cen-
ter, Blakney, 2002
adequate. Many complaints were lodged by
families regarding what they perceived as an
insensitive attitude and manner of communica-
tion from the medical examiners office. Some
families also objected to the rigid application of
the scientific identification process. Among the
complaints and questions relevant to the ME
functions were the following:
Inadequate communication efforts (lack
of information).
Lack of sensitivity to the emotions of
survivors.
Lack of a central point of contact for
information for responders, victims, and
family members.
Lack of a security plan that resulted in
an inability to distinguish personnel,
responding service providers, and other
agents with authority to enter the FAC
and surrounding areas.
Confusion regarding the Victim Identifi-
cation Profile form.
Confusion regarding the identification
process as to length and method used
and its necessity.
Failure to provide adequate isolation for
parents in receiving information.
Location of the media relative to the
FAC; media management in general was
lacking.
Issues surrounding the source and
responsibility for death notifications.
Lack of personnel trained, skilled, and
prepared to assist victims upon receipt
of death notification.
Concern that no one was addressing the
needs of all family members, and
awareness that some family members
were having great difficulty in coping.
No timely or consistent family briefings.
Confusion about who is responsible for
the death notifications and family
assistance.
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
131
Some of these complaints are associated with
the medical examiners office, but others are
not. In fact, no one individual agency or
department of government is charged with the
responsibility of organizing and maintaining a
fully operational family assistance center. This
is an oversight in federal and state policies.
Existing planning guidance, such as the
National Response Plan, parcels out pieces of
the FAC function to various lead agencies, but
places no one agency in charge. The OCME is
clearly identified as being responsible for fatal-
ity management, including death notifications;
also, the state plan calls for OCME to set up a
family victim identification center within the
FAC. Who is supposed to run the FAC is not
addressed.
The university attempted to provide these ser-
vices. In the Virginia Tech Emergency Opera-
tions Plan, the Office of Student Programs is
responsible to:
Develop and maintain, in conjunction with
the Schiffert Health Center, Cook Counsel-
ing Center, the University Registrar, and
Personnel Services, procedures for provid-
ing mass care and sheltering for students,
psychological and medical support services,
parental notification and other procedures
as necessary,
90

A university the size of Virginia Tech must be
prepared for more than emergencies of limited
size and scope. Universities need plans for
major operations. If the situation dictates the
need for additional help from outside the uni-
versity, then all concerned must be prepared to
proceed in that direction.
The university turned to the state for help on
Wednesday, April 17. It should have done so
earlier. The Commonwealth Emergency Opera-
tions Plan in its Emergency Support Function
(ESF) #8 addresses public health and fatality
issues. The Health Department is the lead
agency for this ESF. The OCME mass fatality
plan is found in Volume #4, Hazardous

90
VA Tech Emergency Response Plan, Appendix 10 to
Functional Annex A, page 45.
Materials and Terrorism Consequence Man-
agement Plan, part 14-D-2.
The OCME plan considers 12 or more fatalities
in 1 day in one regional office to be the trigger
point for implementation of the emergency plan.
The plan calls for the establishment of both a
family assistance center and a family victim
identification center. At this location, the OCME
and law enforcement agencies would conduct
interviews to gather antemortem information
and notify next of kin. The OCME, however,
does not have sufficient personnel to perform
this task, and its plan indicates as much (page
16). To their credit, the OCME has recruited a
team of volunteers through the Virginia Funeral
Directors Association to assist in the operation
of a FAC. Funeral directors by training and dis-
position have experience in interactions with
bereaved families. This group is an ideal choice
to provide assistance to the OCME. Unfortu-
nately, this team was not available for the
Virginia Tech incident because the state
requires background checks and ID cards for
these teams and funding was not provided for
them.
What evolved by Wednesday, April 18, was an
uncoordinated system of providing family sup-
port. It was too late and inadequate.
KEY FINDINGS
Positive Lessons
The part of the OCME disaster plan related to
postmortem operations functioned as designed.
The internal notification process as well as staff
redeployments allowed the surge in caseload
generated by the disaster to be handled appro-
priately as well as existing cases and other new
cases that were referred to the OCME from
other events statewide.
Thirty-three positive identifications were made
in 3 days of intense morgue operations.
The contention that the OCME was slow in
completing the legally mandated tasks of inves-
tigation is not valid.
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
132
Crime scene operations with law enforcement
were effective and expedient.
Cooperation with the Department of
Forensic Services for fingerprint and dental
comparison was good.
The OCME performed their technical duties
well under the pressures of a high-profile event.
Areas for Improvement
The public information side of the OCME was
poor and not enough was done to bring outside
help in quickly to cover this critical part of their
duties. The OCME did not dedicate a person to
handle the inquiries and issues regarding the
expectations of the families and other state offi-
cials. This failure resulted in the spread of mis-
information, confusion for victim survivors, and
frustrations for all concerned.
The inexperience of state officials charged with
managing a mass fatality event was evident.
This could be corrected if state officials include
the OCME in disaster drills and exercises.
The process of notifying family members of the
victims and the support needed for this popula-
tion were ineffective and often insensitive. The
university and the OCME should have asked for
outside assistance when faced with an event of
this size and scope.
Training for identification personnel was inade-
quate regarding acceptable scientific identifica-
tion methods. This includes FAC personnel; Vir-
ginia funerals directors; behavioral health, law
enforcement, public health, and public informa-
tion officials; the Virginia Dental Association;
and hospital staffs.
Adequate training for PIOs on the methods and
operations of the OCME was lacking. This train-
ing had been given to two Health Department
public information officers prior to the shoot-
ings. However, since neither was available,
information management in the hands of an
inexperienced public information officer proved
disastrous. This in turn, allowed speculation
and misinformation, which caused additional
stress to victims families.
No one was in charge of the family assistance
center operation. Confusion over that responsi-
bility between state government and the univer-
sity added to the problem. Under the current
state planning model, the Commonwealths
Department of Social Services has part of the
responsibility for family assistance centers. The
university stepped in to establish the center and
use the liaisons, but they were not knowledge-
able about how to manage such a delicate opera-
tion. Moreover, the university itself was trau-
matized.
RECOMMENDATIONS
he following recommendations reflect the
research conducted by the panel, after-
action reports from Commonwealth agencies,
and other studies regarding fatality manage-
ment issues.
X-1 The chief medical examiner should not
be one of the staff performing the post-
mortem exams in mass casualty events; the
chief medical examiner should be manag-
ing the overall response.
X-2 The Office of the Chief Medical Exam-
miner (OCME) should work along with law
enforcement, Virginia Department of
Criminal Justice Services( DCJS), chap-
lains, Department of Homeland Security,
and other authorized entities in developing
protocols and training to create a more
responsive family assistance center (FAC).
X-3 The OCME and Virginia State Police in
concert with FAC personnel should ensure
that family members of the deceased are
afforded prompt and sensitive notification
of the death of a family member when pos-
sible and provide briefings regarding any
delays.
X-4 Training should be developed for FAC,
law enforcement, OCME, medical and
mental health professionals, and others
T
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
133
regarding the impact of crime and appro-
priate intervention for victim survivors.
X-5 OCME and FAC personnel should
ensure that a media expert is available to
manage media requests effectively and that
victims are not inundated with intrusions
that may increase their stress.
X-6 The Virginia Department of Criminal
Justice Services should mandate training
for law enforcement officers on death
notifications.
X-7 The OCME should participate in disas-
ter or national security drills and exercises
to plan and train for effects of a mass fatal-
ity situation on ME operations.
X-8 The Virginia Department of Health
should continuously recruit board-certified
forensic pathologists and other specialty
positions to fill vacancies within the OCME.
Being understaffed is a liability for any agency
and reduces its surge capability.
X-9 The Virginia Department of Health
should have several public information
officers trained and well versed in OCME
operations and in victims services. When
needed, they should be made available to the
OCME for the duration of the event.
X-10 Funding to train and credential vol-
unteer staff, such as the group from the
Virginia Funeral Directors Association,
should be made available in order to utilize
their talents. Had this team been available,
the family assistance center could have been
more effectively organized.
X-11 The Commonwealth should amend its
Emergency Operations Plan to include an
emergency support function for mass fatal-
ity operations and family assistance. The
new ESF should address roles and responsibili-
ties of the state agencies. The topics of family
assistance and notification are not adequately
addressed in the National Response Plan (NRP)
for the federal government and the state plan
that mirrors the NRP also mirrors this weak-
ness. Virginia has an opportunity to be a
national leader by reforming their EOP to this
effect.
A FINAL WORD
The weaknesses and issues regarding the per-
formance of the OCME and the family assis-
tance process that came to light in the after-
math of the Virginia Tech homicides did not
reveal new issues for this agency. In July 2003,
the Commonwealth published Recommenda-
tions for the Secure Commonwealth Panel. Ap-
pendix 1-3 of this report addressed mass fatality
issues. Although the intent of the report was to
assess the state of preparedness in Virginia for
terrorist attacks, many of the issues that arose
following the Virginia Tech homicides were
identified in this report. Had the recommenda-
tions in this report been implemented, many of
the problems cited above might have been
averted.
Therefore, the panel also recommends that the
recommendations found in Appendices 1-3 of the
Secure Commonwealth Panel from 2005 be
implemented.
CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER
133 - A
ADDITIONS AND CORRECTIONS
(No changes from original report.)

135
Chapter XI.
IMMEDIATE AFTERMATH AND THE LONG ROAD TO HEALING
n the hours, days, and weeks following Chos
calculated assault on students and faculty at
Virginia Tech, hundreds of individuals and doz-
ens of agencies and organizations from Virginia
Tech, local jurisdictions, state government, busi-
nesses, and private citizens mobilized to provide
assistance. Once again the nation witnessed the
sudden, unexpected horror of a large number of
lives being intentionally destroyed in a fleeting
moment. Only those caught up in the immediate
moments after the attacks can fully describe the
confusion, attempts to protect and save lives, and
the heartbreaking struggle to recover the dead.
Reeling from shock and outraged by the shoot-
ings, students and faculty who survived Norris
Hall and law enforcement officers and emergency
medical providers who arrived on the scene will
carry images with them that will be difficult to
deal with in the months and years ahead.
Disaster response organizations including com-
munity-based organizations, local, state and fed-
eral agencies, and volunteers eager to help in
any capacity flooded the campus. The media
descended on the grounds of Virginia Tech with a
large number of reporters and equipment, pursu-
ing anyone and everyone who was willing to talk
in a quest for stories that they could broadcast
across the nation to feed the publics interest in
the shocking events.
The toll of April 16, 2007, assaults the senses: 32
innocent victims of homicide, 26 physically
injured, and many others who carry deep emo-
tional wounds. For each, there also are family
members and friends who were affected. Each of
the 32 homicides represents an individual case
unto itself. The families of the deceased as well
as each physically and emotionally wounded vic-
tim have required support specific to their indi-
vidual needs. Finding resolution, comfort, peace,
healing, and recovery is difficult to achieve and
may take a lifetime for some.
The people whose lives were directly affected
include:
Family members of the murdered vic-
tims, who are often called co-victims due
to the tremendous impact of the crimes
on their lives.
Physically and emotionally wounded vic-
tims from Norris Hall and their family
members who, while grateful that they or
their loved ones were spared death, face
injuries that may have a profound effect
upon them for a lifetime.
Witnesses and those within a physical
proximity to the event and their family
members.
Law enforcement personnel who faced
life-threatening conditions and were the
first to respond to Norris Hall and among
the first to respond to West Ambler
Johnston dormitory. They encountered a
scene few officers ever see. Their families
are not sparred from the complicated
impact of the events.
Emergency medical responders who
treated and transported the injured.
Their family members also share in the
complexity of reactions experienced by
emergency medical responders.
Everyone from Virginia Tech who was
part of the immediate response to the
two shooting incidents and the aftermath
that followed.
Mental health professionals.
Funeral home personnel and hospital
personnel, who, while accustomed to
traumatic events, are not necessarily
spared the after-effects.
Volunteers and employees from sur-
rounding jurisdictions and state agen-
cies, and others who worked diligently to
I
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
136
provide support in the first hours and
days.
The campus population of students, fac-
ulty, and staff and their families.
This chapter describes the major actions that
were taken in the aftermath of April 16.
..
Many
other spontaneous, informal activities took place
as well, especially by students. For example,
members of the Hokie band went to the hospitals
and played for some injured students outside
their windows. The madrigal chorus from
Radford University sang at a memorial service
for several students who had been killed. The
private sector made donations and offered assis-
tance. It is difficult to capture the true magni-
tude of the heartfelt responses and the special
kindnesses exhibited by thousands of people.
At the time of publication of this report, recovery
was only 4 months along in a process that will
continue much longer. The following sections dis-
cuss the actions that key responders and entities
took in the immediate aftermath of the shootings
and during the weeks that followed.
FIRST HOURS
fter Cho committed suicide and the scene
was finally cleared by the police to allow
EMS units to move in, the grim reports began to
emerge. The numbers of dead and injured rose as
each new report was issued. Parents, spouses,
faculty, students, and staff scrambled for infor-
mation that would confirm that their loved ones,
friends, or colleagues were safe. They attempted
to contact the university, hospitals, local police
departments, and media outlets, in an attempt to
obtain the latest information.
Chaos and confusion reigned throughout the
campus in the immediate aftermath. Individuals
and systems were caught unaware and reacted to
the urgency of the moment and the enormity of
the event. There was an outpouring of effort to
help and to provide for the safety of everyone.
Responders scrambled to offer solace to the
despairing and to meet emergency needs for
medical care and comfort to the injured. These
initial spontaneous responses helped to stabilize
some of the impact of the devastation as it
unfolded.
Grief-stricken university leaders, faculty, staff,
and law enforcement worked together to monitor
the rapidly changing situation and set up a loca-
tion where families could assemble. Some family
members arrived not knowing whether their
child, spouse, or sibling had been taken to a hos-
pital for treatment for their wounds, or to a
morgue. University officials designated The Inn
at Virginia Tech as the main gathering place for
families.
ACTIONS BY VIRGINIA TECH
he immediate tasks were to provide support
to the families of Virginia Tech students and
particularly to the family members of the slain
and injured. Countless responders including law
enforcement officers, concerned volunteers, gov-
ernment entities, community-based organiza-
tions, victim assistance providers, faculty, staff,
and students worked diligently to lend assistance
in this uncharted territory, the impact of a mass
murder of this scale. Many aspects of the post-
incident activities went well, especially consider-
ing the circumstances; others were not well han-
dled.
The incident revealed certain inadequacies in
government emergency response plan guidelines
for family assistance at mass fatality incidents.
Also, certain state assistance resources were not
obligated quickly enough and arrived late.
Finally, the lack of an adequate university emer-
gency response plan to cover the operation of an
onsite, post-emergency operations center (and
most particularly a joint information center) and
a family assistance center hampered response
efforts.
A variety of formal and informal methods were
used to assist surviving victims and families of
deceased victims.
University-Based Liaisons The Division of
Student Affairs organized a group of family liai-
sons, individuals who were assigned to two or
A
T
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
137
more families for the purpose of providing direct
support to victim survivors. The liaison staff was
comprised of individuals from the Division of
Student Affairs, the graduate school, and the
Provosts Office. They were tasked to track down
and provide information to families of those
killed and to victim survivors, to assist them
with the details of recovering personal belong-
ings and contacting funeral homes, and to act as
an information link between families and the
university. Liaisons worked out the details on
such matters as transportation, benefits from
federal and state victims compensation funds (as
that information became available), coordination
with the Red Cross, travel arrangements for out-
of-country relatives, and much more. They also
helped arrange participation in commencement
activities where deceased students received
posthumous degrees.
Interviews with victims families revealed that
many of the liaisons were viewed as sensitive,
knowledgeable, caring, and helpful. Originally
set up as a temporary resource for the early days
and weeks following the shootings, the liaisons
soon discovered that the overwhelming needs
and expectations for their assistance would be
ongoing. Many liaisons continued to help even as
the weeks stretched on, while others were not in
a position to continue on at such an intense level
for an extended period of time. Still others were
not prepared to serve in the capacity of a liaison
and lacked training and skills needed to provide
assistance to crime victims.
There were a few reports of poor communication,
insensitivity, failure to follow-up, and
misinformation, which added to the confusion
and frustration experienced by a number of
families. Largely, these problems occurred
because Liaisons were volunteers untrained in
responding to victims in the aftermath of a major
disaster. Nevertheless, they were willing and
available to fill an acute need while system based
victim
assistance providers awaited the required
invitation before they were authorized to respond
to Virginia Tech campus. The liaisons
themselves had little if any experience in dealing
with the aftermath of violent crime scenes and
were grappling with their own emotional
responses to the deaths and injuries of the
students and faculty. Liaisons did not have
adequate information on the network of services
designed for victims of crime until at least 2 days
later when most of the states victim assistance
team arrived.
In general, most families reported that their liai-
sons were wonderful and conscientious, and they
were grateful for the tremendous amount of time
and effort put forth by them on their behalf.
State Victims Services and Compensa-
tion Personnel Assistance to survivor fami-
lies and families of the injured could have been
far more effective if executed from the beginning
as a dual function between university-assigned
liaisons and professional victim assistance pro-
viders working together to meet the ongoing
needs of each family
Victim assistance programs throughout the
nation are supported by federal, state, and local
governments. Many victim assistance programs
are community based and specific to domestic
violence and sexual assault crimes, while other
programs are system-based and operate out of
police departments, prosecutors offices, the
courts, and the department of corrections. These
programs provide crisis intervention, counseling,
emotional support, help with court processes,
links to various resources, and financial assis-
tance to victims of crime. They represent a net-
work of trained, skilled professionals accustomed
to designing programs and strategies to meet the
specific needs of crime victims. Moreover, all
states have a victim compensation program
charged with reimbursing crime victims for cer-
tain out-of-pocket expenses resulting from crimi-
nal victimization.
Patricia Snead, Emergency Planning Manager at
the Virginia Department of Social Services
(DSS), alerted Mandie Patterson, Chief of the
Commonwealths Victim Services Section (VSS)
at the Department of Criminal Justice Services
(DCJS), at 12:21 p.m. on April 16, and asked that
office to stand by for possible mobilization to
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
138
support the needs at Virginia Tech. At that
point, it was unclear whether DCJS staff from
Richmond or local advocates would be needed to
staff a family assistance center and whether
Virginia Tech would request assistance for these
services per the states emergency management
procedures. According to those procedures, before
VSS staff can move forward, they must be
authorized to do so from DSS. There was no fur-
ther instruction that day from DSS.
The following day, April 17, the DCJS chief of
VSS sent a broadcast e-mail to the 106 victim
witness programs in Virginia to determine the
availability of advocates with experience in
working with victims of homicide. At 4:17 p.m.
that day, DSS sent a message to DCJS, VSS and
the victim advocates from local sister agencies
indicating that they were authorized to respond
to the needs of victims on the campus. The team
of victim service providers arrived on April 18,
2 days after the massacre. Thus, even though the
Commonwealths emergency plan authorizes
immediate action, the process moved slowlya
real problem given the substantial need for early
intervention, crisis response, information and
help in establishing the family assistance center.
According to Snead, time was lost while officials
from the state and the university worked
through the question of who was supposed to be
in charge of managing the emergency and its
aftermath: the state university or the state gov-
ernment. Reportedly, the university was guarded
and initially reluctant to accept help or relin-
quish authority to the Commonwealth for man-
aging resources and response.
Mary Ware, Director of the Department of
Criminal Injuries Compensation Fund (CICF),
arrived on Tuesday around midnight. Early on
Wednesday morning, she began providing the
services of her office and talked to two on-scene
staff from the Montgomery County Victim Wit-
ness Program. Kerry Owens, director of that pro-
gram, told the panel, You have never seen such
pain, sorrow, and despair in one place, and you
have never seen so many people come together
for a common cause. The CICF provides funds to
help compensate victim survivors with medical
expenses, funeral and burial costs, and a number
of other out-of-pocket expenses associated with
criminal victimization. At Virginia Tech, CICF
enabled the rapid provision of funds to cover fu-
neral expenses, temporarily setting aside certain
procedures until they could be processed at a
later date. CICF staff and the team of victim ser-
vice providers orchestrated by DCJS arrived on
Wednesday morning and proceeded to help in
various capacities.
The delay in the mobilization and arrival of the
victim service providers resulted in some fami-
lies working directly with the medical examiner
regarding that offices request for personal items
with fingerprints or DNA samples to help iden-
tify the bodies. Though the university liaisons
were helping, a number of families did not have
the benefit of a professional victim service pro-
vider to support them in coping with the MEs
requests. Many families had scattered and begun
making arrangements with funeral homes, which
had a direct line to the MEs office. Other non-
governmental service providersmany without
identification or a security badgeappeared on
the scene without having been summoned to
help. As a consequence, some families received
conflicting information about what the Red Cross
would pay for, what the state would cover, and
what they would have to manage on their own.
The victim assistance team comprised of the
states two relevant agenciesDCJS and CICF
had difficulty locating and identifying victim
survivors. Victim Services and Crime Compensa-
tion staff became aware that the United Way
was fund-raising on campus and sought out
those individuals to ensure that there were no
conflicts or duplications of effort. The victim as-
sistance team provided assistance for family
members by informing them of their rights as
crime victims and offering assistance in a num-
ber of areas to include help with making funeral
arrangements, childcare in some instances, ar-
ranging for transportation, emotional support
and referral information. Unfortunately, when
many of the family members returned home to
other states or other parts of Virginia, they were
not connected directly to available services in
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
139
their local jurisdictions. Because of the need to
respect privacy and confidentiality, victim assis-
tance providers in the victims hometowns had to
refrain from intruding and instead had to await
invitation or authorization by others to become
linked to the families. There was a gap in the
continuum of care as, in many cases, survivors
returned home with little or no information re-
garding ongoing victim services in their jurisdic-
tions. To the extent the liaisons had sufficient
information about victims assistance services to
tell the families, they did. However, unless the
liaison or other responsible on-scene providers
provided families and victims with specific in-
formation regarding their local victim services
office, they did not know what services were
available or how to access them.
The Family Assistance Center The Inn at
Virginia Tech became the de facto information
center and gathering place where everyone con-
gregated to await news on the identification of
the wounded and deceased. It also was desig-
nated as a family assistance centera logical
choice for families who needed lodging, informa-
tion, and support. Accommodations at the inn
(rooms, food, and staff service) were well
received, and hotel staff offered special care to
the families who stayed there. However, the
sheer magnitude of the immediate impact cou-
pled with the failure to establish an organized,
centralized point of information at the outset
resulted in mass confusion and a communica-
tions nightmare that remained unabated
throughout the week following the shootings.
The official Virginia Tech FAC was set up in one
of the ballrooms at Skelton Conference Center at
the Inn. Over the first 36 hours, 15 victim advo-
cates from several victim assistance programs
arrived and formed a victim assistance team
comprised of seven staff from the Office of CICF
and other service providers and counselors. Addi-
tionally, staff from the Office of the Chief Medi-
cal Examiner (OCME) was assigned to supervise
the family identification section (FIS) at the
FAC. The FIS, according to the OCME Fatality
Plan will receive inquiries on identification,
prepare Victim Identification Profiles, and collect
any materials, records, or items needed for con-
firmation of identification.
A FAC also is supposed to serve as a safe haven,
a compassion center, and a private environment
created to allow victims and surviving family
members protection from any additional distress
brought about as a result of intrusive media. In
addition to serving as an information exchange
mechanism, the FAC affords victims and family
members refreshments, access to telephones for
long-distance calls, and support from mental
health counselors and victims service providers.
Arriving media, unfortunately, were situated in
a parking lot directly across from the inn. Fami-
lies had to traverse a labyrinth of cameras and
microphones to reach the front desk at the inn.
The media were a constant presence because
they were stationed in the same area rather than
at a site farther away on Virginia Techs large
campus. The impact of the media on victim sur-
vivors is enormous. In high-profile murder cases
the murderer instantaneously is linked to the
victims and together become household names.
Some members of the press were appalled at the
tactics that some of their colleagues used to
gather information on campus at the family
assistance center.
There was little organization and almost no veri-
fiable information for many hours after the
shooting ended. The operative phrase was go to
the inn but once there, families struggled to
know who was responsible for providing what
services and where to go for the latest news
about identification of the dead victims. Some
unidentified people periodically asked families if
they needed counseling. Those offers were pre-
mature in the midst of a crisis and information
was the most important thing that families
wanted at the time.
Family members were terrified, anxious, and
frantic to learn what was happening. Who had
survived? Which hospital was caring for them?
Where were the bodies of those who had perished
taken and how can one get there? There was no
identified focal point for information distribution
for family members or arriving support staff. For
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
140
decades, disaster plans have underscored the
importance of having a designated public
information officer (PIO) who serves as the reli-
able source of news during emergencies. The PIO
serving at the FAC was inexperienced and over-
whelmed by the event. He was unable to ade-
quately field inquires from victim survivors. Help
from the state arrived later, but here again,
repairing the damage caused by misinformation
or no information at all became all but impossi-
ble.
Guests at the inn, officials from state govern-
ment, and others reported a chaotic scene with
no one apparently in charge. From time to time,
small groups of families were pulled aside by law
enforcement officials or someone working in pub-
lic information to hear the latest information,
leaving other families to wonder why they could
not hear what was happening and what the
information might mean for their own relative
whose condition was in question. A number of
victim families eventually gave up hope of learn-
ing the status of their spouse, son, or daughter
and returned home.
Without a formal public information center, ade-
quately staffed, the ability to maintain a steady
stream of updates, control rumors, and commu-
nicate messages to all the families at the same
time was seriously hampered. Here is where
advance planning for major disasters provides
jurisdictions with a template and a fighting
chance to appropriately manage the release of
information.
The university did establish a 24-hour call center
where volunteers from the university and staff
from the Virginia Department of Emergency
Management responded to an enormous volume
of calls coming into the school.
Two of the most deeply disturbing situations
were the dearth of information on the status and
identification of Chos victims and the instances
where protocol for death notifications was
breached. The authority and duty for this grim
task falls usually to law enforcement, hospital
emergency room personnel, and medial examiner
offices. Victim advocates, clergy, or funeral
directors ideally accompany law enforcement
during a death notification. Reports are that law
enforcement, where involved, conducted sensitive
and caring death notifications to family mem-
bers.
Virginia State Police officers, in some instances
with local law enforcement, personally carried
the news no one wants to hear to victims homes
around Virginia late into the night of the 16th.
Officers also coordinated with law enforcement
in other states who then notified the families in
those jurisdictions. Not all families, however,
were informed in that manner. One family
learned their child was dead from a student. In
another case, a local clergy member took it upon
himself to inform a family member that their
loved one was dead while they were on an eleva-
tor at the Inn. The spouse of a murdered faculty
member saw members of the press descend on
her home before his death had been confirmed.
The victims were known to faculty and friends
across campus. As a result, information circu-
lated quickly through an informal network,
which allowed a few family members, who lived
in the immediate area and who arrived quickly
at the inn, to connect with those who were help-
ing to locate the missing. Families who lived out
of the area had to rely on the telephone to obtain
information. Lines were busy and connections
were clogged. They were referred from one num-
ber to another as they tried to track down infor-
mation that would confirm or deny their worst
fears.
Until Friday, April 20, families reported that
they had to think of what questions to ask and
then try to locate the right person or office to
answer the question. The intensity of their pain
and confusion would have been diminished
somewhat if they had received regular briefings
with updates on the critical information sought
by all who were assembled at the inn. It would
have helped if there had been a point person
through whom questions were channeled. The
liaisons and the victim assistance team did the
best they could, but for the most part they were
in the dark as well.
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
141
To make room for all the individuals who needed
to stay at the inn, many resource personnel like
Virginia State Police and others were housed in
dormitories at nearby college campuses like
Radford University.
Counseling and Health Center Services
The universitys Cook Counseling Center quickly
led efforts to provide additional counseling re-
sources and provide expanded psychological as-
sistance to students and others on campus. They
extended their hours of operation and focused
special attention on individuals who lived at the
West Ambler Johnston dormitory, surviving stu-
dents, who were in Norris Hall at the time of the
incident, roommates of deceased students, and
classmates and faculty in the other classes where
the victims were enrolled. The victims had par-
ticipated in various campus organizations, so
Cook Counseling reached out to them as well.
Dozens of presentations on trauma, post-incident
stress, and wellness were made to hundreds of
faculty, staff, and student groups. The center
helped make referrals to other mental health
and medical support services. The center sent 50
mental health professionals to the graduation
ceremonies several weeks later, recognizing that
the commencement would be an exceptionally
difficult time for many people. Resource informa-
tion on resilience and rebounding from trauma
was developed and distributed, including posting
on the Internet.
Schiffert Health Center at the university sent
medical personnel to the hospitals where injured
victims were being treated to check on their well
being and reassure them of follow-up treatment
at Schiffert if needed. The medical personnel
included some psychological screening questions
into their conversations with the injured stu-
dents so that they could monitor the students
psychological state as well.
Other University Assistance The Services
for Students with Disabilities Office began inves-
tigating classroom accommodations that might
be needed for injured students and planned for
possible needs among students with psychologi-
cal disabilities. The Provosts Office announced
flexible options for completing the semester and
for grading. The college deans, the faculty, and
Student Affairs were helpful in advising students
and helping them complete the semester. Aca-
demic suspensions and judicial cases were de-
ferred.
Cranwell International Center provided compli-
mentary international telephone cards to stu-
dents who needed to contact their families
abroad and assure them they were safe. Center
staff called each Korean undergraduate and
many Korean graduate students and, with the
Asian American Student Union and Multi-
cultural Programs and Services, assured each
one of the universitys concern for their safety.
They especially addressed potential retaliation
and requests from the press.
Residence Life asked resident advisors to speak
personally with each resident on campus and
make sure they were aware of counseling ser-
vices as they grappled with lost friends or room-
mates. Housing and Dining Services provided
complimentary on-campus meals for victims
families and friends at graduation. Several of the
victims were graduate students at Virginia Tech.
The graduate school helped open the multipur-
pose room in the Graduate Life Center as a place
for graduate students to gather and receive
counseling services. They also aided graduate
assistants in continuing their teaching and
research responsibilities.
Hokies United is a student-driven volunteer
effort that responds to local, national, and inter-
national tragedies. In addition to a candlelight
vigil, this group organized several well-attended
activities designed to bring the campus commu-
nity together.
Human Resources requested assistance from the
universitys employee assistance provider, which
sent crisis counselors immediately. The counsel-
ors worked with faculty and staff on issues of
self-care, recovery, how to communicate the
tragedy to their children, and other subjects.
After 4 weeks, more than 125 information ses-
sions had been held and 800 individuals had
been individually counseled.
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
142
MEETINGS, VISITS, AND OTHER
COMMUNICATIONS WITH FAMILIES
AND WITH THE INJURED
resident Steger, Governor Kaine, and
Attorney General McDonnell visited injured
students in area hospitals to reassure them of
the universitys and the Commonwealths con-
cern for their recuperation. President Steger also
met with many families over the following
weeks. Governor Kaine held a private meeting
with families who were dealing with the death of
their child, husband, or wife and another meet-
ing with injured students and their families.
On April 19 Governor Kaine appointed the
Virginia Tech Review Panel to examine the facts
surrounding April 16. After appointment, panel
chairman Gerald Massengill sent a letter to all
families of the deceased to express condolences
and offer to meet with anyone who wished a pri-
vate audience with up to two members of the
panel. (As noted in Chapter I, FOIA rules require
that such meetings be public if more than two
members participate.) The letter also offered
them the opportunity to speak at one of the four
public meetings that were to be scheduled in dif-
ferent parts of the state. Several families took
advantage of a special web site that was created
as a tool for collecting information and com-
ments. Others communicated their thoughts
through letters. The chairman sent a similar let-
ter to injured students.
Over the next several weeks, a number of fami-
lies communicated their desire to meet. Others
preferred their privacy, which of course was
respected. Panel members and staff held at least
30 meetings (in individual and group sessions)
with families of the murdered victims and with
injured students and their parents, and fielded
more than 150 calls. The governor designated
Carroll Ann Ellis as the panels special family
advocate. She spent many days initiating and
returning calls to provide information and to
help families regarding their individual issues
and concerns. Many with whom the panel met or
talked with by phone noted appreciation for the
assistance and support they had received and for
the work of the panel.
Several families raised concerns about poor coor-
dinationwhat they saw as failings of the uni-
versity, of responders, of communicators, of vol-
unteers, of the panel and staff, and more. Some
demanded financial restitution; most focused on
relating what society had lost with those 32 lives,
who by all measures were outstanding individu-
als whose achievements and character were
making a difference in the world. The families
asked the panel and the Commonwealth to find
out what went wrong and change what needs to
be changed so others might be spared this hor-
ror. That has been the overriding concern of the
governor and of the panel.
Family members of homicide victims of mass
fatalities tend to view their experiences and the
impact of the crime from the following perspec-
tives:
The overwhelming event and the system
response to the scale of the event. Very
often, the victims become categorized as
a group rather than as individuals (e.g.,
9/11 and Oklahoma City victims). The
particular needs of each victim can be
overlooked as the public perceives them
as a unit rather than as separate fami-
lies. Victims are attuned to whether they
received the information and care atten-
tion that they needed. Victim survivors
want to know what happened, how it
happened, and why their loved was
killed. They look for resources that can
adequately respond to their needs and
answer their questions, though some
answers may never be found.
Death notifications have long-term
impact on victims. Survivors typically
remember the time, place, and manner in
which they first learned of the death of
their loved ones.
Where is the justice? Victim survivors
look to the criminal justice system to
hold the murderer accountable for the
crime. Cho ended his life and denied the
P
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
143
criminal justice system and its partici-
pants the justice that comes from a con-
viction and eventual sentencing.
A homicide differs from other types of death
because it
Is intentional and violent.
Is sudden and unexpected.
Connects the innocent victim to the mur-
derer in a relationship that is disturbing
to family members of the dead victim.
Creates an aura of stigma that surviving
family members often experience.
Is a criminal offense and as such is asso-
ciated with the criminal justice system.
It has the problematic overlap of symp-
toms created by the victim survivors
inability to move through the grief proc-
ess because of a preoccupation with the
trauma experience cause by a homicidal
death. This completed grief reaction is
identified as traumatic grief.
Is pursued by the media and is of inter-
est to the public.
Meeting the overwhelming needs of the families
of homicide victims and fulfilling those expecta-
tions to a level each one finds acceptable is ex-
tremely challenging when there is a mass mur-
der. So many people need the same information
and services simultaneously. Systems are
severely tested because disasters cause the
breakdown of systems and create chaos. Without
a well-defined plan, navigating through the af-
termath is an uphill struggle at best. Even when
plans are in place, the quality and degree of
response to victims of disaster are often inconsis-
tent. A small change in the initial conditions of a
sensitive system can drastically affect the out-
come.
All deaths generate feelings of anger, rage and
resentment. In the case of a murder, and espe-
cially when the shooter commits suicide, survi-
vors are denied their day in court and the oppor-
tunity for the justice system to hold that person
accountable. This adds insult to the terrible
injury they already are experiencing. In these
cases, accurate information in real time is
imperative if survivors are to develop a sense of
trust in the very systems they now must count
on to explain what happened, and why it hap-
pened. When for a variety of reasons that does
not occur, relatives of homicide victims can
experience increased trauma.
Each family has its own particular way of proc-
essing the death of a loved one, because each life
taken was unique. Several grievances, however,
were shared widely among the victims families
as well as questions they wanted the panels
investigation to address. Among the major con-
cerns and questions were the following:
What are the facts and details of the first
responder and university response to the
first shooting, including the decision
process, timing, and wording of the first
alert?
What were the assumptions regarding
the relationship between the first two
victims, and why were they made?
Did those assumptions affect the nature
and timeliness of the subsequent first
alert?
What are the facts and details of the first
responder and university response when
the shooting at Norris Hall began?
With so many red flags flying about Cho
over a protracted period of time, how was
it that he was still living in the dorm and
allowed to continue as a student in good
standing? Why were the dots not con-
nected?
Was Chos family notified of any or all of
his interactions with campus police, the
legal system, and the mental hospital?
Why was there no central point of contact
or specific instructions for families of vic-
tims at The Inn at Virginia Tech?
Why were identifications delayed when
wallet identifications, photos, and other
methods available would hasten the
release of remains?
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
144
Who was responsible for ensuring that
the media was properly managed, and
who was supposed to be the authoritative
source of information?
What is going to be done with the Hokie
Fund and what about other crime com-
pensation funds?
What common sense practices regarding
security and well being will be in place
before students return to campus?
What changes to policy and procedures
about warnings have been made at
Virginia Tech?
These and many other issues all have been ex-
amined by the panel and the results presented
throughout this report.
With regard to the individuals who Cho
injured physically and emotionallytheir
wounds may take a long time to heal if they ever
can heal completely. Many of the men and
women who were in the classrooms that Cho at-
tacked and who survived, bravely helped each
other to escape, called for help, and barricaded
doors. Others were too severely wounded to
move. These men and women in Norris Hall not
only witnessed the deaths of their colleagues and
professors, but on a physical and emotional level
also experienced their dying. The terror of those
who survived Chos attacks in the classrooms
was increased by the silence of death as the liv-
ing harbored somewhere between life and death.
Exposure to such an overwhelmingly stressful
event quite often leads to post traumatic stress
disorder (also known as critical incident stress)
represented by an array of symptoms that range
from mild to severe and which are not always
immediately apparent..
The law enforcement officers and emergency
medical providers who were the first to witness
the carnage, rescue the living, and treat and
transport the physically wounded were exposed
to significant trauma. Their healing also is of
concern.
CEREMONIES AND MEMORIAL
EVENTS
eople seek ways to share their grief when
tragic events occur. The university commu-
nity came together in many ways, from small
prayer groups to formal ceremonies and candle-
light vigils. Cassell Coliseum was the site of con-
vocation on Tuesday, April 17. President George
Bush, Governor Tim Kaine, University President
Charles Steger, noted author and Professor
Nikki Giovanni, and leaders from four major
religions spoke to a worldwide television audi-
ence and 35,000 people in attendance divided
between the coliseum and Lane Stadium. Per-
haps the most poignant event, however, was the
student-organized candlelight vigil later that
evening. One by one, thousands of candles were
lit in quiet testimony of the shared mourning
that veiled every corner of the campus. Stones
were placed in a semicircle before the reviewing
stand to honor the victims of the previous days
shooting. Mourners wrote condolences and
expressed their grief on message boards that
filled the area, while flowers, stuffed animals,
and other remembrances were left in honor of
the professors and students who died in a dorm
room and in classrooms.
VOLUNTEERS AND ONLOOKERS
isasters draw an enormous response. At
Virginia Tech, hundreds of volunteers came
to offer their services; others arrived in unofficial
capacities to promote a particular cause, and
many drove to Virginia Tech to share the grief of
their friends and colleagues. As occurs during
many disasters, some special interest groups
with less than altruistic intentions arrived in
numbers and simply took advantage of the situa-
tion to promote their particular cause. One group
wore T-shirts to give the impression they were
bona fide counselors when their main goal was to
proselytize. Others wanted to make a statement
for or against a particular political position.
Legitimate resources can be a great asset if they
can be identified and directed appropriately. An
emergency plan should define where volunteers
P
D
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
145
should report and spells out procedures for regis-
tration, identification, and credentialing. That
way, available services can be matched to imme-
diate needs for greater effectiveness.
COMMUNICATIONS WITH THE
MEDICAL EXAMINERS OFFICE
ith regard to identifying the victims, every-
thing was done by the book and with care-
ful attention to exactness as described in Chap-
ter X. Therein, however, lay the crux of a
wrenching problem for the families. From a clini-
cal perspective, the MEs office can be credited
with unimpeachable results. From a communica-
tions and sensitivity perspective, they performed
poorly.
A death notification needs to be handled so that
families receive accurate information about their
loved one in a sensitive manner and in private
with due respect. The OCME should have taken
into consideration the wishes of the family and
their care and safety once the news was deliv-
ered. Counseling services need to be available to
families during the process of recovering the
remains. The media needs to be managed with
reference to families and their right to privacy,
dignity, and respect. Finally, victims families
need to be given explanations for any delays in
official notifications and then be provided crisis
support in the wake of receiving that news.
For example, families needed to know what
method was being used to identify their loved
one, and when and how the personal effects
would be retuned. Some families were told that
identification would take 5 days and were given
no explanation why. Some families did not un-
derstand why autopsies had to be performed.
Some wondered about getting copies of the MEs
reports and how they could obtain those. The
MEs office attached this information to each
death certificate, but they concur this may not
have been sufficient.
DEPARTMENT OF PUBLIC SAFETY
any families interviewed by the panel praised
Virginia Secretary of Public Safety John
Marshall and the efforts of the Virginia State
Police during the days following the murders.
Marshalls leadership coalesced resources at the
scene. The state police, with some help from
campus police, mobilized to assist the medical
examiner. They collected records and items from
homes to help confirm the identities of the
deceased and they carried official notification of
death to the families. State troopers also
provided security at The Inn at Virginia Tech to
prevent public access to the FAC.
Finally, in the aftermath of April 16, the panel
has discerned no coordinated, system-wide
review of major security issues among Virginias
public universities. With the exception of the
Virginia Community College System, which
immediately formed an Emergency Preparedness
Task Force for its 23 institutions, the responses
of the state-supported colleges and universities
appear to be uncoordinated.
While Governor Kaine covered a large conference
on campus security August 13, to the panels
knowledge, there have been no meetings of
presidents and senior administrators to discuss
such issues as guns on campus, privacy laws,
admissions processes, and critical incident man-
agement plans. The independent colleges and
universities met collectively with members of the
panel, and the community colleges have met
them twice. The presidents of the senior colleges
and universities declined a request to meet with
members of the panel June 26, saying it was not
timely to do so.
KEY FINDINGS
Mass fatality events, especially where a crime is
involved, present enormous challenges with
regard to public information, victim assistance,
and medical examiners office operations. Time is
critical in putting an effective response into
motion.
W
M
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
146
Discussions with the family members of the
deceased victims and the survivors and their
family members revealed how critical it is to
address the needs of those most closely related to
victims with rapid and effective victim services
and an organized family assistance center with
carefully controlled information management
Family members of homicide victims struggle
with two distinct processes: the grief associated
with the loss of a loved one and the wounding of
the spirit created by the trauma. Together they
impose the tremendous burden of a complicated
grieving process.
Post traumatic stress is likely to have affected
many dozens of individuals beginning with the
men and women who were in the direct line of
fire or elsewhere in Norris Hall and survived,
and the first responders to the scene who dealt
with the horrific scene.
While every injured victim and every family
members of a deceased victim is unique, much of
what they reported about the confusion and dis-
organization following the incident was similar
in nature.
Numerous families reported frustration with
poor communications and organization in the
universitys outreach following the tragedy,
including errors and omissions made at com-
mencement proceedings.
A coordinated system-wide response to public
safety is lacking. With the exception of the
Virginia community College System, which im-
mediately formed an Emergency Preparedness
Task Force for its 23 institutions, the response of
the state-supported colleges and universities has
been uncoordinated. To the panels knowledge,
there have been no meetings of presidents and
senior administrators to discuss such issues as
guns on campus, privacy laws, admissions proc-
esses, and critical incident management plans.
The independent colleges and universities met
collectively with members of the panel, and the
community colleges have met with panel mem-
bers two times. The presidents of the senior col-
leges and universities declined a request to meet
with members of the panel June 26, saying it
was not timely to do so.
RECOMMENDATIONS
he director of Criminal Injuries Compensa-
tion Fund and the chief of the Victim Ser-
vices Section (Department of Criminal Justice)
conducted internal after-action reviews and pre-
pared recommendations for the future based on
the lessons that were learned. The recommenda-
tions with which the panel concurred are incor-
porated into the following recommendations.
XI-1 Emergency management plans should
include a section on victim services that
addresses the significant impact of homi-
cide and other disaster-caused deaths on
survivors and the role of victim service pro-
viders in the overall plan. Victim service pro-
fessionals should be included in the planning,
training, and execution of crisis response plans.
Better guidelines need to be developed for federal
and state response and support to local govern-
ments during mass fatality events.
XI-2 Universities and colleges should
ensure that they have adequate plans to
stand up a joint information center with a
public information officer and adequate
staff during major incidents on campus. The
outside resources that are available (including
those from the state) and the means for obtain-
ing their assistance quickly should be listed in
the plan. Management of the media and of self-
directed volunteers should be included.
XI-3 When a family assistance center is cre-
ated after a criminal mass casualty event,
victim advocates should be called immedi-
ately to assist the victims and their families.
Ideally, a trained victim service provider should
be assigned to serve as a liaison to each victim or
victims family as soon as practical. The victim
service should help victims navigate the agencies
at the FAC.
XI-4 Regularly scheduled briefings should
be provided to victims families as to the
status of the investigation, the
T
CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
147
identification process, and the procedures
for retrieving the deceased. Local or state vic-
tim advocates should be present with the fami-
lies or on behalf of out-of-state families who are
not present so that those families are provided
the same up-to-date information.
XI-5 Because of the extensive physical and
emotional impact of this incident, both
short- and long-term counseling should be
made available to first responders, students,
staff, faculty members, university leaders,
and the staff of The Inn at Virginia Tech.
Federal funding is available from the Office for
Victims of Crime for this purpose.
XI-6 Training in crisis management is
needed at universities and colleges. Such
training should involve university and area-wide
disaster response agencies training together
under a unified command structure.
XI-7 Law enforcement agencies should
ensure that they have a victim services sec-
tion or identified individual trained and
skilled to respond directly and immediately
to the needs of victims of crime from within
the department. Victims of crime are best
served when they receive immediate support for
their needs. Law enforcement and victim ser-
vices form a strong support system for provision
of direct and early support.
XI-8 It is important that the states Victims
Services Section work to ensure that the
injured victims are linked with local victim
assistance professionals for ongoing help
related to their possible needs.
XI-9 Since all crime is local, the response to
emergencies caused by crime should start
with a local plan that is linked to the wider
community. Universities and colleges should
work with their local government partners
to improve plans for mutual aid in all areas
of crisis response, including that of victim
services.
XI-10 Universities and colleges should cre-
ate a victim assistance capability either in-
house or through linkages to county-based
professional victim assistance providers for
victims of all crime categories. A victim
assistance office or designated campus vic-
tim advocate will ensure that victims of
crime are made aware of their rights as vic-
tims and have access to services.
XI-11 In order to advance public safety and
meet public needs, Virginias colleges and
universities need to work together as a
coordinated system of state-supported insti-
tutions.

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING
147 - A
ADDITIONS AND CORRECTIONS
University-appointed Liaisons: p. 136, Correction Each liaison assigned by Virginia
Tech had one or more families to assist, not two or more.


B1
Appendix B.
INDIVIDUALS INTERVIEWED BY
RESEARCH PANEL
(Revised, with corrections to some names and titles.)
APPENDIX B. INTERVIEWEES
B2
The Virginia Tech Review Panel conducted more than 200 interviews. The interviewees in-
cluded family members of victims; injured victims; students; and individuals from universities,
law enforcement, hospitals, mental health organizations, courts, and schools. During the course
of the review, the interviews were conducted in person, through public meetings, by phone, and
through group meetings. A number of people were interviewed multiple times.
The panel wishes to express its appreciation to everyone who graciously provided their time
and comments to this undertaking.
In 2009 several changes were made to this list to correct titles and spellings of some names. , and to re-
flect preferences for how some are listed.
Virginia Tech
Carl Bean English Department Faculty
Cathy Griffin Betzel Cook Counseling Center
Erv Blythe Vice President for Information Technology
Tom Brown Dean of Students
Sherry K. Lynch Conrad Cook Counseling Center
Fred DAguilar English Department Faculty
Ed Falco English Department Faculty
Christopher Flynn, PhD. Director, Cook Counseling Center
David R. Ford Vice Provost for Academic Affairs
Nikki Giovanni English Department Faculty
Kay Heidbreder University Counsel
Bob Hicok English Department Faculty
Zenobia Lawrence Hikes Vice President for Student Affairs
Lawrence G. Hincker Associate Vice President for University Relations
Maggie Holmes Office Manager, West Ambler Johnston Hall
Jim Hyatt Vice President and Chief Operating Officer
Frances Keene Director, Judicial Affairs
Gail Kirby Associate Vice President for Student Affairs
Judy Lilly Associate Vice President
Heidi McCoy Director of Administrative Operations, News and External Relations
Jim McCoy Capital Design and Construction
Lenwood McCoy Liaison of University President to Panel
Jennifer Mooney Coordinator Undergraduate Counseling
Jerome Niles Dean, College of Liberal Arts and Human Sciences
Lisa Norris English Department Faculty
Lynn Nystrom
Director, News and External Relations, College of Engineering (fac-
ulty in Norris Hall)
Ishwar Puri Chairman, Engineering Mechanics Dept. (faculty in Norris Hall)
Kerry J. Redican President, Faculty Senate
APPENDIX B. INTERVIEWEES
B3
Lucinda Roy Past Chair, English Department
Carolyn Rude Chair, English Department
Joe Schetz Aerospace and Ocean Engineering Faculty
Maisha Marie Smith Cook Counseling Center
Ed Spencer Associate Vice President for Student Affairs
Charles Steger President
Other Universities and Colleges
Richard Alvarez Chief Financial Officer, Hollins University
Grant Azdell College Chaplain, Lynchburg College
Mary Ann Bergeron Virginia Community Services Board
Walter Bortz President, Hampden-Sydney College
William Brady, MD University of Virginia, Department of Emergency Medicine
William Thomas Burnett, MD Medical Director of the Virginia State Police Div 6 SWAT Team
Valerie J. Cushman Athletic Director, Randolph College
Susan Davis

University of Virginia, Special Advisor/Liaison to the General Counsel,
Office of the Vice President for Student Affairs
Chris Domes Chief Admissions Officer, Marymount University
Roy Ferguson Executive Assistant to the President, Bridgewater College
Pamela Fox President, Mary Baldwin College
Ken Garren President, Lynchburg College
Nancy Gray President, Hollins University
Robert B. Lambeth President, Council of Independent Colleges in Virginia
Robert Lindgren President, Randolph-Macon College
Greg McMillan Executive Assistant to President, Emory and Henry College
Katherine M. Loring Vice President for Administration, Virginia Wesleyan College
Courtney Penn Special Assistant to the President, Roanoke College
Herb Peterson Vice President for Business and Finance, University of Richmond
Richard Pfau President, Averett University
Jeff Phillips Director of Administrative Services, Ferrum College
Michael Puglisi President, Virginia Intermont College
Robert Reiser, MD Department of Emergency Medicine, University of Virginia
James C. Renick Senior Vice President, American Council on Education
Robert Satcher President, Saint Pauls College
LeeAnn Shank General Counsel, Washington and Lee University
Wesley Shinn Dean, Appalachian School of Law
Douglas Southard Provost, Jefferson College of Health Sciences
Phil Stone President, Bridgewater College
Loren Swartzendruber President, Eastern Mennonite University
APPENDIX B. INTERVIEWEES
B4
Melvin C. Terrell Vice President of Student Affairs, Northeastern Illinois University
Madelyn Wessel
Special Advisor/Liasion to the General Counsel and Chair, Psychologi-
cal Assessment Board, University of Virginia
William Woods, MD Department of Emergency Medicine, University of Virginia
Andrea Zuschin Dean of Student Affairs, Ferrum College
National Higher Education Associations
Robert M. Berdahl President, Association of American Universities
George R. Boggs President and CEO, American Association of Community Colleges
Susan Chilcott
Vice President for Communications, American Association of State
Colleges and Universities
Charles L. Currie President, Association of Jesuit Colleges and Universities
Benjamin F. Quillian Senior Vice President, American Council on Education
James C. Renick Senior Vice President, American Council on Education
David Ward President, American Council on Education
Law Enforcement
Donald J. Ackerman Assistant Special Agent-in-Charge, FBI Criminal Division (NY)
Joey Albert Captain, Virginia Tech Police Department
Richard Ault Supervisory Special Agent for the FBI, (ret.), Academy Group Inc.
Kenneth Baker
Supervisory Special Agent for the FBI, U.S. Secret Service (ret.), Acad-
emy Group Inc., Manassas, VA
Ed Bracht Director of Security, Hofstra University
David Cardona Special Agent-in-Charge, FBI Criminal Division (NY)
Rick Cederquist Counter-Terrorism Coordinator, Union County (NJ) Sheriff's Office
Don Challis Chief, College of William and Mary Police Department
Kim Crannis Chief, Blacksburg Police Department
Lenny Depaul U.S. Marshal's Service (NY/NJ), Fugitive Task Force
Robert C. Dillard
Chief, University of Richmond Police Department and President, Vir-
ginia Association of Chiefs of Police
Jonathan Duecker Assistant Commissioner, New York Police Department
Chuck Eaton Special Agent, Salem, VA, Virginia State Police
Samuel Feemster Supervisory Special Agent for the FBI, Behavioral Science Unit
Martin D. Ficke
SES Resources International/ Special Agent-in-Charge (ret.) Immigra-
tion and Customs Enforcement (NY)
W. Steve Flaherty Superintendent, Virginia State Police
Wendell Flinchum Chief, Virginia Tech Police Department
Kevin Foust Supervisory Special Agent for the FBI, Roanoke, VA
Vincent Giardani New York Police Department Counter-Terrorism Division
Michael Gibson U. Va Chief of Police
Christopher Giovino SES Resources/Dempsey Myers Co.
APPENDIX B. INTERVIEWEES
B5
Ray Harp
SWAT Team Commander and Homicide Detective, Arlington County
(VA) Police Department (ret.)
Charles Kammerdener New York Police Department, Special Operations Division
Robert Kemmler
Lt. Col., Virginia State Police; Deputy Director, Bureau of Administra-
tion and Support Service
Kenneth Lanning Supervisory Special Agent for the FBI (ret.)
Jeff Lee
Active Shooter Training Program, International Tactical Officers Or-
ganization
Stephen Mardigian Supervisory Special Agent for the FBI (ret.), Academy Group Inc.
George Marshall New York State Police
Raymond Martinez New York Police Department Counter-Terrorism Division
Bart McEntire
Resident Agent-in-Charge, Bureau of Alcohol, Tobacco, Firearms and
Explosives, Roanoke, VA
William McMahon
Special Agent-in-Charge, Bureau of Alcohol, Tobacco, Firearms and
Explosives, Roanoke, VA
Ken Middleton High-Intensity Drug Traffic Agency (NY/NJ)
Terrence Modglin Executive Director, College Crime Watch
Andrew Mulrain Nassau County, New York Police Department.
Eliud P. Pagan Office of Homeland Security, State of New York
Chauncey Parker Director, High-Intensity Drug Traffic Agency (NY/NJ)
Robert Patnaude Captain, New York State Police
Alfred Perales Sergeant, University of Illinois Police Department, Chicago, IL
Kevin Ponder Special Agent, FBI Criminal Division (NY)
David Resch Chief, Behavioral Analysis Unit, FBI, Quantico, VA
Anthony Rocco Nassau County, New York Police Department.
Jill Roark
Terrorism and Special Jurisdiction, Victim Assistance Coordinator,
Federal Bureau of Investigation
Bradley D. Schnur Esq. President, SES Resources International Inc.
Dennis Schnur Chairman, Police Foundation of Nassau County Inc.
Andre Simons
Supervisory Special Agent for the FBI, Behavioral Analysis Unit,
Quantico, VA
Sean Smith
Sergeant, Emergency Response Team Virginia Tech Police Depart-
ment
Philip C. Spinelli Union County, New Jersey Office of Counter-Terrorism
Matt Sullivan
Detective/Lt. Suffolk County, New York Police and Hostage Negotia-
tion Team
Bob Sweeney
Lieutenant, Suffolk County, New York Police Emergency Services Bu-
reau
Thomas Turner Director of Security, Roanoke College
Shaun F. VanSlyke
Supervisory Special Agent for the FBI, Behavioral Analysis Unit,
Quantico, VA
Anthony Wilson Sergeant, Emergency Response Team, Blacksburg Police Department
Jason Winkle
President, Active Shooter Training Program, International Tactical
Officers Organization
APPENDIX B. INTERVIEWEES
B6
Joan Yale Nassau County, New York Police Department
Families of Victims
Ms. Lynette. Alameddine Mother of Ross Alameddine
Stephanie Hofer Wife of Christopher James Bishop
Mr. and Mrs. Dennis Bluhm Parents of Brian Roy Bluhm
Mr. and Ms. Cloyd Parents of Austin Michelle Cloyd
Mrs. Patricia Craig Aunt to Ryan Christopher Clark
Ms. Betty Cuevas Mother of Daniel Alejandro Perez
Mrs. Linda Granata Wife of Kevin P. Granata
Mr. Gregory Gwaltney Father of Matthew Gregory Gwaltney
Marian Hammaren and Chris Foote Mother and Stepfather of Caitlin Millar Hammaren
Mr. John Hammaren Father of Caitlin Millar Hammaren
Mr. Michael Herbstritt Father of Jeremy Michael Herbstritt
Mr. and Mrs. Eric Hilscher Parents of Emily Jane Hilscher
Mrs. Tracey Lane Mother of Jarret Lee Lane
Mr. Jerzy Nowak Husband of Jocelyne Couture-Nowak
Mr. William ONeil Father of Daniel Patrick ONeil
Mrs. Celeste Peterson Mother of Erin Nicole Peterson
Mr. and Mrs. Larry Pryde Parents of Julia Kathleen Pryde
Mr. and Mrs. Peter Read Parents of Mary Karen Read
Mr. and Mrs. Joseph Samaha Parents of Reema Joseph Samaha
Mrs. Holly Adams-Sherman Mother of Leslie Geraldine Sherman
Mr. Girish Suratkal Brother of Minal Hiralal Panchal
Mr. and Mrs. Paul Turner Parents of Maxine Shelly Turner
Ms. Liselle Vega-Coates Ortiz Wife of Juan Ramon Ortiz
Mr. and Mrs. White Parents of Nicole Regina White
Cho Family
Mr. and Mrs. Cho Parents of Seung Hui Cho
Sun Cho Sister of Seung Hui Cho
Wade Smith
Attorney at Law, Tharrington Smith, Raleigh, NC; Advisor, Friend to
Cho Family
Injured Victims and Their Families
Alec Calhoun Student, Virginia Tech
Colin Goddard Student, Virginia Tech
Suzanne Grimes Mother of Kevin Sterne
Emily Haas Student, Virginia Tech
Mrs. Lori Haas Mother of Emily Haas
APPENDIX B. INTERVIEWEES
B7
Jeremy Kirkendall Virginia National Guard
Mrs. Miller Mother of Heidi Miller
Erin Sheehan Student, Virginia Tech
Rescue Squads
Allan Belcher Carilion Patient Transportation Services
Sidney Bingley Blacksburg Volunteer Rescue Squad
William W. Booker IV Virginia Tech Rescue Squad
Charles Coffelt Carilion Patient Transportation Services
Paul Davenport Carilion Patient Transportation Services
Jeremy Davis Virginia Tech Rescue Squad
Jason Dominiczak Virginia Tech Rescue Squad
Kevin Hamm Christiansburg Rescue Squad
Matthew Johnson Captain, Virginia Tech Rescue Squad
Tom Lovejoy Blacksburg Volunteer Rescue Squad
Alisa Nussman Virginia Tech Rescue Squad
John OShea Blacksburg Volunteer Rescue Squad
Neil Turner Montgomery County EMS Coordinator
Colin Whitmore Virginia Tech Rescue Squad
Hospitals
Carole Agee Legal Counsel, Carilion Hospital
Deborah Akers Lewis-Gale Medical Center
Pat Campbell Director of Nursing, New River Valley Medical Center
Candice Carroll Chief Nursing Officer, LewisGale Medical Center
Loressa Cole
Montgomery Regional Hospital
Susan Davis
Special Advisor/, Liaison to the General Counsel, Office of the Vice
President for Student Affairs
Michael Donato, MD Carilion Roanoke Memorial Hospital Emergency Room
Robert Dowling, MD LewisGale Medical Center
Patrick Earnest Carilion New River Valley Medical Center
Ted Georges, MD Carilion New River Valley Medical Center
Carol Gilbert, MD EMS Regional Medical Director
Mike Hill Director, Emergency Department, Montgomery Regional Hospital
Scott Hill
Chief Executive Officer, Montgomery Regional Hospital
Anne Hutton Manager, CONNECT, Carilion Hospital
Judith M. Kirkendall Administrator, Criminal History Records, Richmond, VA
David Linkous Director, Staff Development and Emergency Management, Montgom-
ery Regional Hospital
Rick McGraw Carilion Roanoke Memorial Hospital Emergency Room
APPENDIX B. INTERVIEWEES
B8
William Modzeleski Assistant Deputy Secretary, U.S. Department of Education
John OShea
Lieutenant and Cardiac Technician, Blacksburg Volunteer Rescue
Squad
Fred Rawlins, DO Carilion New River Valley Medical Center
Mike Turner Clinical Support Representative, Carilion St. Albans
Holly Wheeling, MD Montgomery Regional Hospital
Federal, State, and Local Agencies
Marcella Fierro, MD Chief Medical Examiner, VA
Robert Foresman Director of Emergency Management, Rockbridge County, VA
Mandie Patterson
Chief Victim Service Section, Department of Criminal Justice Ser-
vices, VA
Patricia Sneed Emergency Planning Manager, Virginia Department of Social Services
Jessica Stallard Assistant Director, Victim Services, Montgomery County, Virginia
Karen Thomas Virginia Department of Criminal Justice Services
Mary Ware Director, Criminal Injuries Compensation Fund
Mental Health Professionals
Harvey Barker, MD
Director of Crisis and Intervention, New River Community Service
Board
Richard Bonnie
Director, Institute of Law, Psychiatry and Public Policy, University of
Virginia
Gail Burruss
Director, Adult Clinical Services and Crisis Intervention, Blue Ridge
Behavioral Healthcare
Pam Kestner Chappalear Executive Director, Council of Community Services
Lin Chenault Executive Director, New River Community Service Board
Katuko T. Coelho Center for Multicultural Human Services
Roy Crouse Independent Evaluator for Commitment
Joan M. Ridick Depue Clinical Psychologist, Pastoral Counseling, Culpeper, VA
Russell Federman
Director, Counseling and Psychological Services, University of Vir-
ginia
Kathy Godbey New River Community Service Board, pre-screener for commitment
James Griffith, MD Psychiatrist, Center for Multicultural Human Services
Kathy Highfield Blue Ridge Behavioral Healthcare
Dennis Hunt Executive Director, Center for Multicultural Human Services
D. J. Ida
Clinical Psychologist and Executive Director, National Asian Ameri-
can and Pacific Islander Mental Health Association
Jerald Kay , MD
Chair, College Mental Health Committee for the American Psychiatric
Association, Chair of the Department. of Psychiatry, Wright State
School of Medicine
Wun Jung Kim, MD Psychiatrist and Professor, University of Pittsburgh
Jeanne Kincaid ADA/OCR , Attorney with Drummond Woodson
Francis Lu, MD
Chair, APA Council on Minority Mental Health and Health Dispari-
ties, Professor of Clinical Psychiatry, UCSF
APPENDIX B. INTERVIEWEES
B9
James Madero
Clinical Psychologist, Former NIMH Staff/School Violence Specialist,
California School of Professional Psychologists at Alliant International
University
Kent McDaniel, MD Consultant Psychiatrist to the Office of the Inspector General, VA
Jasdeep Migliani, MD Staff Psychiatrist, St Albans Medical Center, Carilion Health System
Frank Ochberg, MD Former Director of Michigan Department of Mental Health
Carrie Owens Director of Victim Services, Montgomery County, VA
Annelle Primm, MD
Director, Division of National and Minority Affairs, American Psychi-
atric Association
Andres Pumariega, MD
Chair of the Diversity Committee for the American Psychiatric Asso-
ciation, Chair Department of Psychiatry, Reading Hospital, PA
James S. Reinhard
Commissioner, Virginia Department of Mental Health, Mental Retar-
dation and Substance Abuse Services
Gregory B. Saathoff, MD
Executive Director, Critical Incident Analysis Group, University of
Virginia
Les Saltzberg Executive Director, New River Community Service Board
Jim Sikkema Executive Director, Blue Ridge Behavioral Healthcare
Bruce Smoller, MD President-elect, Medical Association of Maryland; HPC
James W. Stewart III
Inspector General, Virginia Department of Mental Health, Mental
Retardation and Substance Abuse Services
Terry Teel Attorney for Commitment
Clavitis Washington-Brown Blue Ridge Behavioral Healthcare
Richard West
Psychologist, Research on Preventing Campus Mental Health-Related
Incidents
Courts/Hearing Officials
Paul Barnett Special Justice
Donald J. Farber Attorney at Law, San Rafael, CA
Lorin Costanzo Special Justice, Virginia
John Molumphy Special Justice, Virginia
Joseph Graham Painter Attorney, Former Special Justice
High School Staff
Dede Bailer

Director, Psychology and Preventative Services, Fairfax County Public
Schools
Rita Easley School Guidance Counselor, Westfield High School
Frances Ivey Former Assistant Principal, Westfield High School
Students at Virginia Tech
Joseph Aust Cho Roommate
Chandler Douglas Resident Advisor
John Eide Cho Roommate
Andy Koch Cho Suitemate
Austin Morton Cho Resident Advisor
APPENDIX B. INTERVIEWEES
B10
Melissa Trotman Resident Advisor
Business
Kathleen Schmid Koltko-Rivera President, Professional Services Group, Winter Park, FL
Mark E. Koltko-Rivera
Executive Vice President, Professional Services Group, Winter Park,
FL
Other
Steve Capus President, NBC News
Steven Erickson Father of Stalking Victim
Mr. Gibson Father of Stalking Victim
David McCormick Vice President, NBC News
Luke Van Heul Former Member, Delta Force