Critical Incident Stress Assessment Form
Please complete this form to help us understand your responses and needs following a critical incident. Your answers will assist in providing appropriate support.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Critical Incident Experienced
*
Workplace accident
Violence or assault
Natural disaster
Sudden loss
Other
How soon after the incident are you completing this assessment?
*
Immediately (within 24 hours)
1-3 days
4-7 days
More than a week
Please rate the intensity of your current stress related to the incident.
*
No stress
0
1
2
3
4
5
6
7
8
9
Extreme stress
10
0 is No stress, 10 is Extreme stress
How frequently have you experienced the following symptoms since the incident?
*
Rows
Never
Rarely
Sometimes
Often
Always
Intrusive thoughts or memories
1
2
3
4
5
Difficulty sleeping
6
7
8
9
10
Irritability or anger
11
12
13
14
15
Feeling numb or detached
16
17
18
19
20
Physical symptoms (e.g., headache, stomach upset)
21
22
23
24
25
How well are you able to perform your daily activities since the incident?
*
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to perform
Please indicate how much support you feel you have received since the incident.
*
No support
0
1
2
3
4
5
6
7
8
9
Excellent support
10
0 is No support, 10 is Excellent support
Which coping strategies have you used since the incident? (Select all that apply)
*
Talking with friends or family
Seeking professional help
Physical exercise
Relaxation techniques
Avoidance or withdrawal
Other
Have you experienced any thoughts of self-harm or harming others since the incident?
*
No
Yes, occasionally
Yes, frequently
Is there anything else you would like to share about your experience or needs at this time?
Submit Assessment
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