Response Activated on Date *
The person responsible for activating this Critical Response is *
This person becomes the Critical Response (CR) Coordinator
Select… Myself Someone Else
What is the nature of this incident? *
What date and time did it happen? *
Who else has been contacted, other than the CR Coordinator?
What is the current state of the situation? Is it stable? Is it safe?
What program does this critical incident relate to?
Where did the critical incident occur?
Select… At location listed above At another location
Please list contact details for Team Leader spoken to:
Name, phone number etc
Please list contact details for any other Leader spoken to:
Name, phone number etc
Number of participants at event where critical incident occurred:
Age range of participants at event where critical incident occurred:
Number of Team Members at event where critical incident occurred:
Person #1 - Details of Injury
Person #1 - Next of Kin
Name, telephone and address
Which Emergency Services have been called?
Time call/s made:
Please note exact time call was made and by whom.
What is happening with the rest of the group? (Team members and participants)
Details of group evacuation if necessary
How is the Team Leader coping?
Offer a supportive statement if appropriate
How are the rest of the team handling the situation?
How are the participants coping with the situation?
Is this a situation where individual counselling is likely to be of assistance?
Do any of the participants need to be taken home?
If yes, please list name, address and phone (so counsellor and organisational representative can meet them and their caregivers)
What level of media activity is occurring?
Ask the Team Leader if they can pass on the names and phone contacts of any media personnel at the location
Would it be useful and practical to have a Critical Incident Response Director (CIRD) sent to the location?
If so, note their needs in relation to transport, food, accommodation, clothing, and anything else the CIRD needs to take to the site.
Should a counsellor or team of counsellors also travel to the site?
If so, who should go, when and how?
How will the Critical Incident Response Team take over responsibility for managing the critical incident and what should happen to assist the Team Leader and the rest of the program?
Signatures of Team Members / Leaders completing this report *
Please tick all that apply, print out and sign this form.
Submit
