CISM ACTION REPORT SHEET Submit the following action report after each event. Place a check next to the appropriate contact type. The form will be sent to [email protected] and [email protected] after submission.Date of Event: MM slash DD slash YYYY Date of CISM Event: MM slash DD slash YYYY EAP Referral Brief Description of Event:Select Nature of CISM Action One-on-One(Meeting with peer) Defusing(Initial quick group meeting after critical incident. May hand out info materials, but it is informal and will be immediately following event) Debriefing(Formal after action event, should be 24-72 hours post event and must have a clinician present) Consultation(Meeting with clinician or referral to do so) Follow Up(Check-in after initial contact. Can be via text/phone/in-person) Educational/Other Educational/Other:(List type below. Can be therapy dog visits, etc.)Role of Attendees: Communications PD FD/EMS Chaplain Clinician Other Other Attendee Role: Total number of attendees present: CISM Team Participation# of CISM members present: Name of Team member(s)# of Clinicians present: Name of Clinicians:Reason for CISM Activity Death/Injury of Coworker Suicide of Coworker Injury/Death of a Child Extensive Media Coverage EMD Complication Civilian Death/Injury Mass Casualty Death following a prolonged event Unusual/bizarre event Other Other Reason for CISM ActivityDescribe
