CALIFORNIA FIREFIGHTER PEER SUPPORT AND CRISIS REFERRAL SERVICES ACT CURRICULUM APPROVAL FORM

CALIFORNIA FIREFIGHTER PEER SUPPORT AND CRISIS REFERRAL SERVICES ACT CURRICULUM APPROVAL FORM
For local or regional public fire agencies to be eligible for the confidentiality protections afforded by California Firefighter Peer Support and Crisis Referral Services Act (AB1116), the training shall be approved by the California Firefighter Joint Apprenticeship Committee.
Applicant Information
Name

First NameLast Name
Organization/Fire Department
Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Curriculum Acknowledgement
Is your curriculum already listed as an "Approved Training Program" on healingourown.org?
Name of Approved Training Program
Course Overview
Course Title
Course Description
Total Instructional Hours
Delivery Format
Total Number of Facilitators
Name of Primary Facilitator

First NameLast Name
Organization/Fire Department
Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years of Fire Service Experience
Years of Peer Support Experience
Resume, Certification(s), and/or Supporting Documentation

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Name of Secondary Facilitator

First NameLast Name
Organization/Fire Department
Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years of Fire Service Experience
Years of Peer Support Experience
Resume, Certification(s), and/or Supporting Documentation

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Name of Secondary Facilitator

First NameLast Name
Organization/Fire Department
Title/Role
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years of Fire Service Experience
Years of Peer Support Experience
Resume, Certification(s), and/or Supporting Documentation

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Curriculum Elements
Pre-Crisis Education
Please identify where the "Resiliency" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Suicide Intervention" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Post-traumatic Stress Disorder & Post-traumatic Stress Injury" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Life Altering Events" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Marriage and Family" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Workplace Stressors" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "One-on-One Support Services" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Active Listening Skills" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Crisis Intervention Techniques
Please identify where the "One-on-One Support Services" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Active Listening Skills" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Defusing" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Debriefing" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "On-scene Support Services" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Resource Services
Please identify where the submitted materials outline local behavioral health resources (e.g., slide number, lesson title, module, and/or page number).
Please identify where the submitted materials identify culturally competent behavioral health providers (e.g., slide number, lesson title, module, and/or page number).
Please identify where the submitted materials acknowledge member access to culturally competent clinician(s) (e.g., slide number, lesson title, module, and/or page number).
Referral Services
Please identify where the "Treatment Programs" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Self-help Groups" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Financial Planning" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Parenting" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Victim of a Crime" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Grief Support" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Understanding Confidentiality Requirements" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Substance Abuse Awareness and Approaches" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
Please identify where the "Suicide Risk Assessment, Support, and Referral" content is located within your submitted materials (e.g., slide number, lesson title, module, and/or page number).
File Upload
Course Outline

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Instructional Materials (slide deck(s, handouts, etc)

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Course Completion Certificate

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Letters of Recommendation and/or Endorsement(s)

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Attestation

I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge.
Signature

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CALIFORNIA FIREFIGHTER PEER SUPPORT AND CRISIS REFERRAL SERVICES ACT CURRICULUM APPROVAL FORM

Applicant Information

Curriculum Acknowledgement

Course Overview

Curriculum Elements

File Upload

Attestation