FV CISM Intake Form
Date: / Time: / Dispatcher:Requestor: / County of Request:
Person to Contact:
Street: / Service Requested:
City/State/Zip: / Urgency:
Phone: / Referred to (DF):
Alt. Phone: / Referral to DF Date / Time:
Event
Services:
- Scene Support (Demobilization)
- Defusing
- Debriefing
- Presentation/Education
- Other
Peer Coordinators:
- EMS:
- Steve Radich (Gold Cross): W:, H:, P:
- Fire Fighters:
- Dave Goyke (Appleton FD): W:, H:, P:
- Hospital:
- K.C. Schuler (ThedaCare): W, H: , P:
- Kelly Nies (ThedaCare EAP): W:
- Law Enforcement:
- Lori Ranke (Calumet Co. Sheriff)
W:, H:
a)Central phone number to request a debriefing: Gold Cross Ambulance 920-727-3030.
b)Request for CISM is logged by Gold Cross
c)Initial request with brief description incident referred to a debriefing facilitator (DF):
- Mark Marnocha: (phone numbers listed)
- K.C. Schuler:
- Melissa Lee:
- Don Merz:
- Kurt Mahnke:
d)the initial request log is forwarded to Steve Radich by the dispatcher
e)DF calls person requesting debriefing to evaluate request and need for debriefing
- if need for debriefing is determined, DF sets up time and place in conjunction with person requesting the debriefing
- if debriefing not appropriate, DF can offer other appropriate options for follow up
f)DF calls peer coordinators for peers of the disciplines needed for the debriefing
- peer coordinators arrange for peers to attend debriefing with DF
- peer coordinators arrange for peers to meet with DF ½ hour prior to debriefing to be briefed on the details of the incident and coordinate approach to the debriefing
g)debriefing occurs, including:
- listing of number of attendees, disciplines ,and units present (not including names)
- handouts concerning stress management and responses
- evaluation forms
h)debriefing team meets after the debriefing as a group (DF and peers) to discuss any further team issues, evaluations, and follow-up.
i)the documentation from the debriefing will be filed with K.C. Schuler at Theda Clark
Revised:05/10/2007