Download critical incident stress debriefing (cisd) - M

CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
OR MANAGEMENT (CISM)
PROCESS FOR A CRITICAL INCIDENT
1. If there is a fatality or a life-threatening situation, please call 911 and then the Park Police.
Notify your management team and the manager/supervisor will implement the department
protocol.
2. In all instances call Risk Management to relay the incident and Risk Management will
coordinate with applicable regulatory agencies (i.e.: MOSH, EPA etc.) or coordinate with the
claims administrators (Workers’ Compensation, Property Damage or Liability).
3. If counseling is requested then the rest of the form should be completed to ascertain the amount
and type of services needed.
4. EAP counseling services are only available to employees. The EAP can provide literature that
has been stripped of references to BHS that can be provided to patrons.
INSTRUCTIONS: This form should be completed by the person requesting the services or by the
primary contact for receiving the services. Complete what you can. Don’t let any area slow you
down.
Date of incident: _____________________ Day of Week: ______________________________
Location Name: _________________________________________________________________
Location Address: _______________________________________________________________
Staff Person Requesting Services: ______________________________ Phone #: _____________
Staff Person Completing This Form: ___________________________ Phone #: _____________
Invoicing Account Code(s)
Hourly rate for services: Normal $325 for 1st hr of each session; $225 for subsequent hours of session
Actual Charges: ________________________________________________________________
(Special services are charged to the requesting department’s account(s). An invoice will be sent to the requestor or division chief for approval)
Description of Incident: ___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Special Needs: __________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
OR MANAGEMENT (CISM)
M-NCPPC CONTACTS
The primary & secondary contact is needed if the chosen counselor has a question regarding the
situation or needs help to find the location.
Primary Contact at Location of CISD: _______________________________________________
Position Title: _____________________________________ Phone 1: _____________________
Alternate Phone: __________________________ Alternate Phone: _______________________
Secondary Contact at Location of CISD: _____________________________________________
Position Title: _____________________________________ Phone 1: _____________________
Alternate Phone: __________________________ Alternate Phone: _______________________
Person at M-NCPPC expecting a call back from EAP provider with details:
Gertie Johnson
Phone#: 301-454-1684 OR Who was the contact at the EAP?
Jan Lahr Prock
Phone#: 301-454-1685 OR __________________________________
Jennifer McDonald Phone#: 301-454-1726 OR __________________________________
DHRM General Phone #
301-454-1700
IMPACT ASSESSMENT INTAKE
List of people impacted (directly/indirectly): These would be people who had first hand
interaction with a situation. For example it could be a person’s name or a group of people such as
the lifeguards at the scene of a drowning. Names are better though.
Name
Title
Location
Injuries: Describe the accident or death scene surrounding any injuries and who might have been
injured (patron or employee).
_______________________________________________________________________________
_______________________________________________________________________________
Involvement by authorities:  Yes
 No
by M-NCPPC Park Police  Yes  No
By County Police
 Yes  No
History of previous significant incidents: _____________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
REQUEST FOR ON-SITE SERVICES
Best Date(s)
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Best Time(s)
Notes
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CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
OR MANAGEMENT (CISM)
In the chart below, list the name and address where the CISD will occur.
If there is more than one site that is affected by the incident, list multiple sites.
EAP counseling is only for employees of the M-NCPPC. This service is NOT available to
patrons (adults or children). There are professional liability issues for the EAP provider to
give services to patrons. This chart is used to provide details of the requests and provide a history
of what occurred and who performed the services.
Location (include address) and requested
time of 1 or 2 hours if they differ
Location Name:
Address:
Phone:
Contact:
Duration of Counseling Session  1 hr
 2 hrs
Expected Attendance: ______
Attire for counselors
 business casual
 formal business
Date
Time
Complete
Counselor
Assigned
If scheduling counseling sessions at different sites but at times close to each other, be sure to
include the estimated travel time from one site to another.
WRITTEN MATERIALS
It is possible that a critical incident will affect both employees and patrons. Once Business Health
Services (BHS), our EAP provider is provided with this “intake” sheet, they will offer some
written communications that can be shared with the employees.
We may also request that copies of the written communications be altered to remove any reference
to BHS, our EAP provider and those written communications can be provided to patrons. Please
indicate your preference for receiving written communications.
Request written materials for:  Employees Only
 Employees & Patrons
Patrons Only
To where should the materials be faxed or emailed? List the name(s) after Jan and Jennifer.
Name
Jan Lahr Prock
Jennifer McDonald
Email Address
[email protected]
[email protected]
Fax Phone Number
N/A
N/A
Note: Materials that are emailed are usually sent in PDF format.
What are language requirements/barriers? _____________________________________________
_______________________________________________________________________________
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CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
OR MANAGEMENT (CISM)
Tip Sheets that were sent by BHS: (This provides a history of what materials the EAP provided)
Description
Employees Patrons
1.
2.
3.
Note: sheets for patrons will be stripped of any BHS identifying and contact information.
POST CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
Follow-up Clinical Recommendations by BHS:
1. Continue to monitor the behavior of employees who were directly and indirectly impacted by
the incident and refer them to the EAP as appropriate
2. Remind managers, supervisors and facility directors to encourage employees to use the EAP
for individual support and recommendations
3. Follow-up with managers, supervisors and facility directors on a regular basis to ensure that
impacted staff is coping well.
4. Ask if any employee should have a special follow-up call from BHS (a wellness check) Fee:
$20.00
Follow-up Tip Sheets that were sent by BHS:
1. ________________________________________________________________________
2. ________________________________________________________________________
3. ________________________________________________________________________
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CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
OR MANAGEMENT (CISM)
EVALUATION OF THE SERVICES PROVIDED BY THE BHS EAP
Critical Incident Date: __________
Incident Location: _________________________________
Please rate the services of the EAP provider
Please rate our
services
Courtesy
Speed of Service
Knowledge
Professionalism
Helpfulness
Excellent
Good
Average
Fair
Poor
Comments: ____________________________________________________________________
Please rate the services of the counselor(s)
Please rate our
services
Courtesy
Speed of Service
Knowledge
Professionalism
Helpfulness
Excellent
Good
Average
Fair
Poor
Comments: ____________________________________________________________________
Please rate the services of the Health & Benefits Office (if applicable)
Please rate our
services
Courtesy
Speed of Service
Knowledge
Professionalism
Helpfulness
Excellent
Good
Average
Fair
Poor
Comments: _____________________________________________________________________
Please fax this completed form directly to Business Health Services at: 410-889-7397
Send a copy to Jan Lahr Prock ([email protected]) or fax to 301-454-1687
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