Bay Area CISM Team Membership Application

Bay Area CISM Team Membership Application

Bay Area CISM Team

The Centre for Living with Dying, a program of Bill Wilson Center

Please type or print clearly.

Please mark the category for which you are primarily qualified.

______Mental Health Professional______Peer Support

Personal Information

Name ______

Address ______

Phone: Home______Cell ______Work ______

Social Security Number ______

Educational Information

School AttendedDates of AttendanceDegree Awarded

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______

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Professional Licenses or Certificates held:

______

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If degrees are not within the areas of sociology or psychology, please describe courses or training you have taken in these areas:

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If you are associated with a fire, rescue, police or ambulance service, please identify:

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Employment Information

Beginning with your present job, please list your employers for the past seven years. Use additional paper, if needed.

Company Name Dates of Employment Job Title Reason for Leaving

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______

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(Please include a copy of your resume, if available)

Background and Experience Information

You will need additional paper to answer some of the questions. Please put only the last four numbers of your social security number on additional pages. Please print clearly or type.

1. Have you ever needed the services of Emergency Medical Services or other emergency personnel? ______What happened? ______

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How did you feel about the encounter? ______

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2. How did you hear about the Critical Incident Stress Management Team? ______

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3. Why do you want to become a member of the Team? ______

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4. What assets would you bring to the CISM process if you were a member? ______

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5. What personal deficits do you believe would need to be compensated for through other team members?

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6. What exposure have you had to emergency medical situations, psychological crises, multiple trauma or mass casualty incidents?

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7. Do you have experience in any of the following?

Include the types of clients and amount of direct service time spent in these areas.

a. Individual counseling ______

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b. Small group work ______

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c. Stress management ______

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d. Training or education in other areas ______

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8. List the stress management techniques you have used effectively. ______

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9. Describe any leadership and/or supervisory positions you have assumed or been appointed or elected to.

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10. Have you ever personally experienced signs of stress (emotional, cognitive, physical, behavioral)? Explain fully.

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11. What techniques do you personally use to deal with stress? Explain. ______

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12. Cite examples of how you have managed stressful events in your life. ______

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13. Describe what you believe are the differences and similarities between police, fire and EMS personnel. Please explain.

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14. What do you perceive the role of mental health professionals to be in dealing with CIS in emergency workers? How do you think mental health professionals are perceived by emergency workers, in general?

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15. Comments or additional information you would like us to consider in the CISM Team selection process.

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16. In which areas (e.g. suicide assessment, EMS, fire, police operations) do you believe team members might benefit from additional training?

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17. How much flexibility do you have to go on debriefings on 24 – 48 hour notice?

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18. List three references, not related to you. Include name, address and phone number.

1. ______

______

2. ______

______

3. ______

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Bay Area Critical Incident Stress

Management (CISM) Team

Reference Release

I, ______(please print), hereby authorize the Bay Area Critical Incident Stress Management Team Screening Committee, to contact any school, former places of employment, credit organizations, law enforcement agencies and/or persons who may aid determining my suitability as a Team member.

Additionally, I release those individuals and/or organizations contacted from all liability whatsoever for issuing the requested information.

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Applicant’s signature

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Social Security number

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Date

If previous employment, school, or activities were under another name, please print your former name(s):

______

______

By signing this application, I acknowledge that the information contained herein is, to the best of my knowledge, true and correct. I am providing the information in order to allow my suitability for CISM team membership to be considered. I authorize the Bay Area Critical Incident Stress Management Team to verify the information regarding my personal, educational, employment, activities and references listed above. I understand that this application will remain the property of the Bay Area Critical Incident Stress Management Team. This release is effective for a period of 6 months after the date below.

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Signature

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Date

FACT SHEET

For Individuals Interested in Becoming A CISM Team Member

The Bay Area Critical Incident Stress Management Team was established in September of 1988 by a Task Force of concerned professionals to provide a form of crisis intervention specifically designed to help emergency workers cope with the psychological stresses inherent in their professions. Operational since its adoption by the Centre for Living with Dying in March of 1989, the team provides debriefing for particularly stressful events such as multiple casualty incidents, death of a child, death of a co-worker, traumatic incidents involving mass media coverage, failure of efforts following prolonged intervention and other events that are unusually emotionally stressful.

A Clinical Coordinator receives and screens requests for debriefings. When the need for a formal debriefing is determined, the Clinical Coordinator contacts a three member team consisting of one mental health professional and two emergency workers and schedules the debriefing within a 24 – 72 hour period. Debriefings generally last two to three hours. The Bay Area CISM Team responds to requests from northern California, so the travel time may vary considerably.

The Bay Area CISM Team consists of approximately 20 members who rotate to debriefings on the basis of availability. Other factors considered in dispatching an individual include the type of services the individual represents and not being familiar with individuals being debriefed. Confidentiality of debriefings is imperative to maintain. The volume of debriefings varies from month to month.

Other team member responsibilities include attending monthly CISM Team meetings. The purpose of these meetings includes:

1.Discussion of the dynamics that occurred in the prior month’s debriefings.

2.Providing continuing education services.

3.Providing an opportunity for members to get to know each other before working together at a debriefing.

4.Increasing Team cohesiveness and bonding.

5.Providing a forum for the exchange of ideas, addressing problems and brainstorming.

6.Debriefing the debriefers when necessary.

Members serve on committees and special task groups. They also are assigned to present continuing education programs to groups as requested. Education regarding Critical Incidents is the first step in efficient utilization of the Debriefing Process.

Prospective Team members are asked to complete an application form and a Memorandum of Understanding, as well as attend a screening interview. They are asked to make a one year commitment to serving with the Team. The Team calendar year is July to July. Training is provided for new members and attendance at these sessions is mandatory.

If you have further questions regarding membership on the Team, please contact Janet Childs at the Centre for Living with Dying. The phone number is (408) 278-2512.

Bay Area Critical Incident Stress

Management (CISM) Team

Memorandum of Understanding

I, ______, the undersigned, agree that if I am selected into membership into the Bay Area Critical Incident Stress Management Team Program, will serve as a volunteer team member for a period of one year. I understand that serving as a team member requires the following commitment and obligations:

1.Attendance at the initial 2-day training seminar.

2.Attendance at ongoing monthly meetings, which provide on going training, team-building and support.

3.Completion of cross-training as may be required.

4.Complete any required records and paperwork.

5.Maintain my own malpractice insurance.

6.Revocation/suspension of my membership will occur under the following circumstances but is not limited hereto:

A.If I fail to maintain strict confidentiality regarding CISM debriefings held, including topics discussed and personnel involved. Any breech of confidentiality will result in immediate removal from the team and program.

B.If I fail to follow all local protocols and directives regarding CISM activity.

C.If I organize or in any way attempt to organize a debriefing without the Program Coordinator’s prior knowledge and approval.

D.If I organize on in any way attempt to organize any CISM management activity or program with the Program Coordinator’s prior knowledge and approval,

E.If I go to the scene or place of an incident to act on behalf of the CISM program or team without the Program Coordinator’s prior knowledge and approval.

F.If I fail to be present at an assigned debriefing or activity when I have made a commitment to do so.

G.If I act against the express direction of the Program Coordinator, Clinical Director or Team Leader.

H.If I misrepresent the affairs or operations of the CISM program.

I.If I am habitually or continually absent from scheduled team meetings.

I further understand that being selected to attend the preliminary screening session does not insure me a position on the team or within the program.

The Bay Area Critical Incident Stress Management Debriefing Team agrees to provide:

1.At least 1 continuing education session per year.

2.A local preliminary training session.

3.Administrative support.

4.Debriefing for the debriefing team members when necessary or requested.

5.Re-evaluation of the entire team operation and personnel after each year

of operation.

6.Maintenance of quality standards in performance and confidentiality in personnel (team members) and operation.

7.CISM Team Member Identification for each member.

8.“On Site” team members with safety equipment including, but not limited to, safety helmet or hard hat and a reflective safety device.

9.Team meetings as required or at least on a quarterly basis.

10.Information and updates on the topic of CISM and related issues.

I have read and understood these commitments and obligations and will agree, if selected, to serve as a volunteer for the CISM program and the Team for the Bay Area and to abide by all protocols.

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Signed

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Date