Critical Incident Stress Debriefing Checklist
Complete this checklist to document and assess stress responses following a critical incident.
Full Name
*
First Name
Last Name
Role/Position
*
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Brief Description of the Incident
*
Have you participated in a debriefing before?
*
Yes
No
Please rate your current stress level
*
No Stress
1
2
3
4
5
6
7
8
9
Extreme Stress
10
1 is No Stress, 10 is Extreme Stress
Check any symptoms you are experiencing
Difficulty sleeping
Irritability or anger
Anxiety
Sadness or depression
Fatigue
Physical pain/discomfort
Difficulty concentrating
Other
Please indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel supported by my team.
1
2
3
4
5
I understand my emotional reactions.
6
7
8
9
10
I am able to talk about the incident.
11
12
13
14
15
I feel prepared to return to work.
16
17
18
19
20
I would like additional support.
21
22
23
24
25
What support do you feel would be helpful at this time?
Additional comments or concerns
Submit Checklist
Should be Empty: