First Responder Peer Support Coordinator Directory Form

First Responder Peer Support Coordinator Directory Form

for the 100 Club of Illinois Frontline Provider Network
In response to needs identified by department peer support programs, the 100 Club of Illinois is collecting information about peer support programs statewide to include in our Frontline Provider Network. The purpose of this Peer Support Coordinator Directory is to provide a network of programs and coordinators to collaborate with one another, exchange resources, and share peer support providers when seeking outside agency assistance. The goals of this directory are to:
- Create awareness of peer support teams
- Have a network for assistance during critical incident needs
- Build a collaboration for continuing education training, peer support program procedures, and first responder support resources and services
Directory Submission Process:

This form is to be completed by an agency’s lead Peer Support Coordinator(s). The contact information shared will be included on the Peer Support Coordinator Directory unless otherwise requested by the submittee. This will allow other agencies to reach out to coordinators directly for inquiries about peer support program development and maintenance, program resources, and/or peer support assistance requests.

Listed below are the steps to be added to the Peer Support Coordinator Directory:
1. Complete this online Peer Support Coordinator Directory form
2. The 100 Club of Illinois will schedule a phone call consultation with your program coordinator(s)
3. If added to the Frontline Provider Network, you will be asked to notify the 100 Club of any changes to your profile as they occur, and review your profile on an annual basis
This application is open to all first responder departments and peer support collaborations. There is no cost for participating in this resource.
Peer Support Coordinator Information

Provide the name(s) of your agency's peer support coordinators that will be listed as a point of contact on the Frontline Provider Network. At least one agency point of contact must be provided. This should be the individual who runs the agency's peer support program and can serve as the best liaison when questions or requests are needed.
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Would you like to add an additional Peer Support Coordinator?*

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Would you like to add an additional Peer Support Coordinator?*

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Would you like to add an additional Peer Support Coordinator?*

YesNo
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Department or Agency Information

Provide details of the department or agency who oversees your peer support program that will be listed on the Frontline Provider Network.
Department or Agency Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Agency or Department?*
Please upload your Department or Agency's logo or patch for Provider Network profile purposes:

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How many members are in your agency?*
Agency Peer Support Program Information

Please share some information about your agency's peer support program to provide insight into the resources and assistance your program provides.
Outside of Peer Support, what other wellness resources are available within your department?*

EAPIn-house clinician or social workerIn-house chaplainTherapy K9Wellness spaces (quiet room, gym, etc.); please specify belowOn-duty wellness allowances (gym time, nap time, etc.); please specify belowAnnual mental wellness checksFamily programming or resourcesNone of the aboveOther
Please select those that your peer support program is trained to serve:

Law Enforcement OfficersCorrectionsFirefightersParamedicsDispatchersOther
Number of Peer Supporters
What year was your peer support program established?
Please list the curricula(s) used to train Peer Supporters
Please specify:
What continuing education/peer support certification maintenance requirements do you hold for your peer supporters?
What is your protocol for handling a confidentiality violation or other poor peer supporter conduct?
Do you have peer support members trained for group peer support requests?

YesNo
Do you have peer support members trained for critical incident response (debriefs, diffusings, briefings)?

YesNo
What are the strengths of your peer support program? What successes have you seen come from it?
What obstacles is your peer support program facing? What needs do you have that could make your peer support program stronger?
Other details you would like to share:
Your peer support members are comprised of:

Law Enforcement OfficersCorrectionsFirefightersParamedicsDispatchersOther
Outside Agency Support

Peer Support program can provide collaborative support in many different ways including peer support referrals, program development assistance, and/or resource sharing. Please identify which way(s) you would like to be available and/or which resources you can provide that will be shared through the First Responder Provider Directory.
Are you willing to discuss the development and/or maintenance of a peer support program with others looking to start or coordinate their peer support program?

YesNo
Are you willing to take requests for peer support connections from outside of your agency?

YesNo
If Yes, what timeframe are you able to acknowledge/respond to a peer support request?
Are you willing to take requests for critical incident peer support assistance from outside of your agency?

YesNo
If Yes, what timeframe are you able to acknowledge/respond to a peer support request?
Are you able to provide your peer support policy or protocol documentation, wellness programming language, and/or local first responder providers vetted by your department, to assist others in developing their own documentation? These items can be provided with or without your agency identification (name, logos, etc.) and will only be shared as you provide them.

Yes, I will provide peer support policy or protocol documentationYes, I will provide wellness programming languageYes, I will provide a list of vetted providers that we refer our first responders toYes, I will provide other support documentation that has helped our peer support or wellness programmingNone at this timeOther
Please upload the above documentation for Provider Network profile purposes:

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Are you open to feedback regarding peer support services provided?

YesNo
Are you willing to connect with the 100 Club of Illinois at a minimum annually to renew/update your provider profile?

YesNo
What other departments do you know of who have peer support programs? Please list department, coordinator name, and coordinator email.
Agreement
I understand that by completing this form that:*

This information will be utilized with respect and the intent to provide support to other peer support programs and/or first responders' peer support needsI will maintain communication with the 100 Club of Illinois to update profile information as relevantThe 100 Club of Illinois reserves the right to remove coordinators and/or the entire peer support program from the Provider Network at any point
I, First Name* Last Name* understand and agree to the above statements.
Signature*

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First Responder Peer Support Coordinator Directory Form

Peer Support Coordinator Information

Department or Agency Information

Agency Peer Support Program Information

Outside Agency Support

Agreement