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Arizona Crisis Response Team Information and Application
 

Arizona Crisis Response Team Information and Application

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    Arizona Crisis Response Team Information and Application Arizona Crisis Response Team Information and Application Document Transcript

    • Arizona Crisis Response Team APPLICATION INSTRUCTIONS & REQUIREMENTS To complete your application, Please follow these instructions. This page is for your reference only. Do not submit with your application Applicants for the Arizona Crisis Response Team (AZCRT) must, at a minimum, have attended The National Organization for Victim Assistance’s (NOVA) Basic Crisis Response Team Training Institute, AND/OR 40 hours of training through The International Critical Incident Stress Foundation (ICISF.) Applicants must be able to document a minimum of 200 hours of combined crisis intervention related training and direct experience working with people in crisis situations. Preference is given to applicants that display training and experience that illustrate knowledge of and ability to use crisis response and crisis intervention techniques. All applicants must commit to a minimum of 2 years of volunteer service. To be eligible for state wide and national deployment, all applicants must also complete Federal Emergency Management Agency (FEMA) training in National Incident Management Systems (NIMS 700) and Incident Command Systems (ICS 100.) Applicants must be an active volunteer or staff member working in the fields of criminal justice, emergency or medical services, or social services. At the discretion of the approval committee, a Memorandum of Understanding with your current employer/volunteer coordinator may be requested. All applicants must possess a DPS level 1 clearance card, or provide proof of a passed NCIC background check via their current employer. To submit your application: 1. Provide the following completed original forms in this order: a. Completed application. b. Two recommendation and evaluation forms that attest to your crisis intervention skills, ability, and amount of experience in the field. Forms should be completed by an individual who has observed your work. c. Copies of certificates for all completed NIMS/ICS training. d. Include verification of a passed background check, or current DPS Level 1 clearance card. 2. Make sure all documents are signed where appropriate. 3. Attach supporting documentation attesting to your years of experience, and any training/certifications you wish to have considered. 4. Keep a copy of application for your records. 5. Ensure your contact information; including your email address is correct and legible. 6. Mail or turn in completed application to: ARIZONA COALITION FOR VICTIM SERVICES Attn: AZCRT Committee Post Office Box 3816 Phoenix, AZ 85030-3816
    • Arizona Crisis Response Team APPLICATION FOR TEAM MEMBERSHIP NAME ______________________________________________D.O.B.________________ APPLICATION DATE: ___________ HOME ADDRESS: __________________________________________ CITY: _______________________________ ST: ______ ZIP: ________ HOME PHONE: ( )_____________________OTHER: ____________ EMAIL: ___ _______________________________________________ Please explain your primary professional identity and years of experience within this field that qualify you for the AZCRT. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ ______________________________________________________________________________________________ Please list relevant training that supports your team membership, i.e., psychological first aid, crisis intervention, trauma or grief counseling, disaster management, EMS, firefighter or paramedic training or any training in ICS, NIMS, or CERT. Attach additional page if necessary. (Note: please attach supporting documents/ certifications of related training.) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _____________________________________________________________________________________
    • Please list any organizations or groups in which you have or are currently volunteering with: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ What strengths or qualities do you have that would be helpful in a community crisis intervention team? EMPLOYMENT HISTORY Begin with your most recent job, providing as much detail as you can within the last five years only. Your work history provides a chronology of previous jobs, types of skills utilized and how they led to your interest in the Arizona Crisis Response Team membership. This includes any schooling or education if you were a student within the last five years. 1. Employed From: ______________ To: _______________ Position Title: ________________________ Company/Agency/School:________________________________________________________________ Address: __________________________________City: ________________ St.: _____ Zip: __________ Job Duties: ___________________________________________________________________________ 2. Employed From: ______________ To: _______________ Position Title: ________________________ Company/Agency/School:________________________________________________________________ Address: __________________________________City: ________________ St.: _____ Zip: __________ Job Duties: ___________________________________________________________________________ 3. Employed From: ______________ To: _______________ Position Title: ________________________ Company/Agency/School:________________________________________________________________ Address: __________________________________City: ________________ St.: _____ Zip: __________ Job Duties: ___________________________________________________________________________
    • Please check all categories in which you have professional or volunteer formal training, certification, licensure or experience. Please note certifications, expiration date and years of experience. CERTIFICATION/EXPIRATION YRS./EXPERIENCE  (EDU) EDUCATION _____________/_____ _________  (EMGT) EMERGENCY MANAGEMENT _____________/_____ _________  (EMS) EMERGENCY MEDICAL SERVICES/EMT/PARAMEDIC _____________/_____ _________  (FB) FAITH-BASED/CLERGY/CHAPLAIN/MINISTRIES _____________/_____ _________  (FIRE) FIRE SERVICE _____________/_____ _________  (HOS) HOSPICE _____________/_____ _________  (LAW) LAW ENFORCEMENT _____________/_____ _________  (LGL) LEGAL _____________/_____ _________  (MT) MASSAGE THERAPIST _____________/_____ _________  (MED) MEDICAL SERVICES, NURSE, PHYSICIAN _____________/_____ _________  (MH) MENTAL HEALTH (LCSW, LMFT, CSW, LPC, ETC.) _____________/_____ _________  (MIL) MILITARY _____________/_____ _________  (PH) PUBLIC HEALTH _____________/_____ _________  (SAR) SEARCH & RESCUE _____________/_____ _________  (OTH) OTHER - Explain: _________________________ _____________/_____ _________ Please check all categories in which you have professional or volunteer experience with specific populations and the number of years in each. YEARS SPECIFY EXPERIENCE  Children ________ _____________________________________________  Adults ________ ______________________________________________  Elderly ________ ______________________________________________  Special populations ________ _____________________________________________  Victims of violent crime ________ _____________________________________________ Additional Skills:
    • YEARS SPECIFY EXPERIENCE  Foreign language _______ _____________________________________________  American Sign Language (ASL) ______ ____________________________________________  Suicide/homicide _______ ____________________________________________  Education/Training _______ _____________________________________________  Media _______ _____________________________________________  Other _______ _____________________________________________ Please specify ANY POPULATIONS or types of crisis response work you prefer NOT to do: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please identify any limits on your availability to respond to a crisis, i.e., time, distance, work, family, physical etc. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you ever been arrested or cited for any misdemeanor or any felony offenses?  YES  NO If YES, please explain: __________________________________________________________________ ____________________________________________________________________________________ I agree that all information contained in this application is accurate to the best of my knowledge. Signature _____________________________________ Date _________________________________________ DO NOT EMAIL COMPLETED APPLICATION. Send completed application and attachments by U.S. Mail ONLY to: ARIZONA COALTION FOR VICTIM SERVICES Attn: AZCRT Committee Post Office Box 3816 Phoenix, AZ. 85030-3816 _____________________________________________________________________________________________________________________________________________________________________________________ FOR OFFICE USE ONLY:  Copies of Certifications/Licensure Received STATUS:  Reference Letters Received  Pending  Police Background Check Received  Approved  Denied
    • Arizona Crisis Response Team REFERENCE AND EVALUATION FORM To be completed by someone with the authority to evaluate the Applicant’s work performance as it relates to the provision of crisis intervention/response services by the Applicant. Observation of at least 3 case interventions by someone in a position to evaluate the Applicant’s knowledge and skills is required. Please use separate copies of this form if different individuals have observed Applicant’s interventions. This form must be sealed in an envelope by the evaluator and returned to Applicant for inclusion in the Applicant’s submission packet. Please type or print in black ink. Evaluator Information Applicant Information Full Name: Mailing Address: Full Name: Title: Phone Number: Email Address: Mailing Address: What is your relationship to applicant? How long have you known applicant?
    • Case Intervention Types In the individual or group interventions where you observed the Applicant, what type of crisis victim/survivor was the Applicant serving? Intervention #1 Group Individual Intervention #2 Group Individual Intervention #3 Group Individual
    • Case Intervention Questions Keeping in mind the interventions listed on the previous page, please answer the following questions with a yes or no, and add comments below each question where necessary. 1. Was the Applicant able to create a physically safe and emotionally secure environment for the victim(s)/survivor(s)? Yes No 2. Was the Applicant able to hear the victim(s)/survivor(s) ventilation and provide appropriate validation? Yes No 3. Was the Applicant able to provide useful prediction and preparation to help the victim(s)/survivor(s) consider ways to cope after the intervention? Yes No 4. Was the Applicant able to provide valid education to the victim(s)/survivor(s) on trauma reactions and practical issues? Yes No 4. Was the Applicant able to remain calm and professional if conflict arose with the individual or the group? Yes No 5. Was the Applicant able to identify potentially serious trauma reactions that needed referral to a mental health professional, or, if not relevant in the cases you observed, do you think the Applicant is capable of identifying such situations and making appropriate referrals? Yes No 7. Based upon your opinion, do the Applicant’s demonstrated skills and abilities qualify him or her for acceptance as a crisis responder? Please include an explanation below. All comments will be treated as confidential Yes No If you have any additional comments about the interventions that you observed, please explain here: I have completed the above evaluation and am sealing it in an envelope to be returned to the Applicant for inclusion in the application packet. EVALUATOR NAME: _________________________________ _______________ (PRINT NAME) (DATE) SIGNATURE: ________________________________________
    • Arizona Crisis Response Team REFERENCE AND EVALUATION FORM To be completed by someone with the authority to evaluate the Applicant’s work performance as it relates to the provision of crisis intervention/response services by the Applicant. Observation of at least 3 case interventions by someone in a position to evaluate the Applicant’s knowledge and skills is required. Please use separate copies of this form if different individuals have observed Applicant’s interventions. This form must be sealed in an envelope by the evaluator and returned to Applicant for inclusion in the Applicant’s submission packet. Please type or print in black ink. Evaluator Information Applicant Information Full Name: Mailing Address: Full Name: Title: Phone Number: Email Address: Mailing Address: What is your relationship to applicant? How long have you known applicant?
    • Case Intervention Types In the individual or group interventions where you observed the Applicant, what type of crisis victim/survivor was the Applicant serving? Intervention #1 Group Individual Intervention #2 Group Individual Intervention #3 Group Individual
    • Case Intervention Questions Keeping in mind the interventions listed on the previous page, please answer the following questions with a yes or no, and add comments below each question where necessary. 6. Was the Applicant able to create a physically safe and emotionally secure environment for the victim(s)/survivor(s)? Yes No 7. Was the Applicant able to hear the victim(s)/survivor(s) ventilation and provide appropriate validation? Yes No 8. Was the Applicant able to provide useful prediction and preparation to help the victim(s)/survivor(s) consider ways to cope after the intervention? Yes No 4. Was the Applicant able to provide valid education to the victim(s)/survivor(s) on trauma reactions and practical issues? Yes No 9. Was the Applicant able to remain calm and professional if conflict arose with the individual or the group? Yes No 10. Was the Applicant able to identify potentially serious trauma reactions that needed referral to a mental health professional, or, if not relevant in the cases you observed, do you think the Applicant is capable of identifying such situations and making appropriate referrals? Yes No 8. Based upon your opinion, do the Applicant’s demonstrated skills and abilities qualify him or her for acceptance as a crisis responder? Please include an explanation below. All comments will be treated as confidential Yes No If you have any additional comments about the interventions that you observed, please explain here: I have completed the above evaluation and am sealing it in an envelope to be returned to the Applicant for inclusion in the application packet. EVALUATOR NAME: _________________________________ _______________ (PRINT NAME) (DATE) SIGNATURE: ________________________________________