PSYCHOLOGICAL FIRST AID (PFA) RESPONDER APPLICATION

Disaster Response
Psychological First Aid (PFA)
MHMRA Employee Applicant


Note: press tab to move to the next box in the form—pressing enter will submit the form, so do not press enter until you complete the entire form.


Please fill out the form to create a new MHMRA Applicant record.

Department:
Employee ID:
Job Title:
Supervisors Name :
Supervisor Email:
Supervisors Phone Number :
First Name:
Last Name:
Home Address:
City:
State:
ZIP:

Language Proficiency:

Enter your most fluent Language in order from top to bottom
  
Do you require language accommodation?
No Yes

  
Do you require physical accommodation?
No Yes

Contact Information in case of Emergency Activation:
Indicate the order in which you are to be contacted.
Home Phone:
Work Phone:
Cell Phone:
Personal E-Mail:
Work E-Mail:
Twitter:
Other Device:
Emergency Contacts:
Primary Contact Name:
Relationship:
Phone / Cell:
Secondary Contact Name:
Relationship:
Phone / Cell:

Training History:
Please check off any of the below listed training you have taken and the year the training was completed. Check all that apply.

*Requires certificate of completion of training prior to activation as a PFA Responder. Online courses may be completed for NIMS / Incident Command at: http://training.fema.gov
/IS/NIMS.asp and PFA ONLINE at: http://learn.nctsn.org

Completed
Category
Year
Psychological First Aid**(PFA)
  PFA Training provided by:
DePelchin Red Cross
 
Other:    
IS-700*
IS-100*
IS-200*
Critical Incident Stress Management (CISM)
Basic CPR
Basic First Aid
Basic Disaster Life Support (BDLS)
CERT
NOVA
Other Emergency Responder or Mental Health Training:
Please specify below.

List any other Disaster Response / Relief organizations with which you volunteer:

RedCross MRC CERT   Other, not listed : 
  
List any types of disaster response experience. If none, select No
No Yes
If Yes, list the types of incidents below:
  1. Hurricane
  2. Tornado
  3. Flood
  4. Fire
  5. Disease Outbreak
  6. Other



Licensure:
Please list all currently held professional licenses and expiration dates.

Applying to be a PFA Responder as a Volunteer:
Highest Educational Level:
If working, name of your employer:
Address of your employer:

By checking the box,
    • I affirm that I am at least 18 years old and competent;
    • I certify that the information provided on this application is true and correct to the best of my knowledge;
    • I acknowledge that prior to becoming an active Volunteer PFA Responder, I will be required to sign a confidentiality agreement;
    • I acknowledge that prior to becoming an active Volunteer PFA Responder, I will be required to sign a liability waiver and release that will include authorization for a background check to be conducted on me; and
I accept that my services will be limited to Psychological First Aid consistent with the training and standards defined by Harris County and the City of Houston.
Name:           
Today's Date: 
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