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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
Reason for team activation
- Select One - Death/Injury to Co-worker Mass Casualty Suicide - Co-worker Civilian Death Death/Injury to Child Prolonged Event Extensive Media Coverage Unusual Circumstance Other - (plaese specify below) Terrorisim Incident
Team members present
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