CISM Team Member Reporting

CISM Team Member Report

If you are human, leave this field blank.

Important Notice about HIPPA and PHI

This form is for use by CSEMS CISM Team members only. Please complete one form for each intervention made.

This website is not compliant with the Health Insurance Portability and Accountability Act (HIPAA). Therefore, please do not submit Protected health information (PHI) in this form. PHI under US law is any information about health status, provision of health care, or payment for health care that is created or collected by a "Covered Entity" (or a Business Associate of a Covered Entity), and can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient's medical record or payment history.

Type of Intervention * Type of Intervention

Date of Intervention *

Time of Intervention *

Reason for Team Activation * Reason for Team Activation

Name of Team Members Present *

Location of Intervention

How were you notified? * How were you notified?

Comments *

End Section

Number of Providers Present

EMS Providers *

Fire *

Communications Staff *

Law Enforcement *

Hospital Staff *

Other *

End Section

Submitted By

First Name *

Last Name *

E-mail Address *

Phone Number *

Date of Submission *

End Section

Certification

I certify that the information submitted on this form is true and correct to the best of my knowledge. *

Agree

Disagree

End Section

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CISM Team Member Reporting

Important Notice about HIPPA and PHI

Number of Providers Present

Submitted By

Certification

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