arizona crisis response team information and application

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 SERVICESAttn: AZCRT CommitteePost Office Box 3816 Phoenix, AZ 85030-3816


APPLICATION FOR TEAM MEMBERSHIP

NAME ______________________________________________D.O.B.________________________

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.

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

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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.)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_____________________________________________________________________________________

APPLICATION DATE: ___________

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: _______________________________________________________________________________




Job Duties: _______________________________________________________________________________




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 SERVICESAttn: AZCRT CommitteePost Office Box 3816Phoenix, AZ. 85030-3816

___________________________________________________________________________________________________________________________________________________________________________________________

FOR OFFICE USE ONLY: Copies of Certifications/Licensure Received STATUS: Reference Letters Received Pending Police Background Check Received Approved Denied


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.

Ap

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n Full Name:

Mailing Address:

Eva

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Info

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Full Name:

Title:

Phone Number:

Email Address:

Mailing Address:

What is your relationship to applicant?

How long have you known applicant?

Ca

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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



Ca

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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: ________________________________________


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.

Ap

plic

an

t In

form

atio

n Full Name:

Mailing Address:

Eva

lua

tor

Info

rma

tio

n

Full Name:

Title:

Phone Number:

Email Address:

Mailing Address:

What is your relationship to applicant?

How long have you known applicant?

Ca

se In

terv

en

tio

n T

ypes

In the individual or group interventions where you observed the Applicant, what type of crisis victim/survivor was the Applicant serving?




Ca

se In

terv

en

tio

n Q

ue

stio

ns

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: ________________________________________

arizona crisis response team information and application

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