Incident Report Form - PSO 2025-26

Incident Report Form - PSO

This form is to be completed by Peer Support Officers (PSOs) following any contact with a member concerning an incident.
Reminder: Peer Support is not a counselling service. It is a supportive conversation designed to help members understand the process following a traumatic experience. This is not an operational debrief. If a member requires an operational debrief, please refer them to their Club Captain.
YesNo
YesNo
Details of Peer Support Officer completing this form:
Name*

First NameLast Name
Details of Referred Member:
Name*

First NameLast Name
Over 25Under 25
Details of Incident:

Using the information contained in the SOCC referral, please complete the following questions regarding the incident.
Date of Incident *

DayMonthYear
Date of incident
Nature of Incident*
Location of Incident (Club)*
Details of Contact with Member:
Date of contact with member*

MonthDayYear
Date
YesNo
YesNo - Declined Peer SupportNo Response
Reason for contact:*
PhoneFace to FaceTeams/ZoomTextEmailDeclined Peer SupportOther
YesNoDeclined Peer Support
Lifeline / Beyond Blue / Butterfly Foundation / 13YARNGP - Medicare ReferralNational Emergency Worker Support SchemePsychologist / PsychiatristMember's own support networkNoOther
YesNoDeclined Peer Support
Did the member divulge any additional information or concerns regarding the incident or Peer Support?
YesNoDeclined Peer Support
Should be Empty:

Incident Report Form - PSO