CISM Team Member On-line Application - Mississippi State Department of Health

Disparity Elimination

Educational Events

Emergency Preparedness

EMS-Trauma

Environmental Services

Health Data and Research

Health Education

Institutional & Other

Milk & Bottled Water

Organ Donation

Primary Care Liaison

Radon

Rural Health

Smoke Alarms

Social Services

Water Supply

Water Systems Revolving Fund

CISM Team Member On-line Application

Occupation	Years A minimum of 2 years in your occupation is required
Degree(s)
Licensure/Certifications
Professional Organizations

Employer
Supervisor	Your employer and supervisor will be contacted
Business Address
Work phone(s)

I have had previous training in:

Crisis Intervention	Stress Survival Strategies
Grief or Mourning	Psychological First Aid (PFA)
Suicide Recognition and Intervention	Critical Incident Stress Management

Training details
If you checked any of the above, briefly tell us where and when you received your training, and specifics of what it covered

Do you have any crisis response experience? If so, what was your role?
Do you have any specific time constraints? Include anything that may make it difficult for you to attend team meetings or be available for CISM activities.
What time of the day are you most likely to be available in an emergency?
Why are you interested in participating on the Mississippi CISM Team?


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