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CISM Report Form for Debriefing, Defusing or One-on-One


CSEMS CISM Team Report Form

Intervention Information (Required)

- Select One-

Debriefing Defusing One on one

  Date  Time
Location                

Reason for team activation

     

Team members present

How were you notified? (Required)
 
Number of providers present (Required)
EMS Communications Staff
Fire Hospital Staff
Law Enforcement Other (please specify below)

Do you feel follow up will be needed? (Required)

Yes  No

If Yes please specify below

Comment Box

Please use the space below to clarify information entered above.  All comments, complaints, or recommendations are appreciated

Person completing this form (required)

Name

E-mail

Phone #

Please contact me as soon as possible 

 

 

 

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Central Shenandoah EMS Council
2312 W. Beverley St., Staunton, VA 24401
www.csems.vaems.org