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	Incident Management Team Inc.
IMT Independent Contractor Questionnaire

Name of Licensure:

Home Address

City, State, Zip:

Employer

Employer Address

City, State, Zip

Home Phone

Work Phone

Cell Phone

Pager

Other

Email Address:

DOB

Are you currently licensed to practice independently? Yes No

Federal ID Number or SS#

Type of entity: Sole proprietor/Individual, PA, Corporation, Other _______________________

Are you currently licensed to practice independently? Yes No

Please list current licenses and certifications

Please attach copies of all licensures and certifications

Professional Liability/Malpractice Insurance Insurance:

Carrier Name:

Please attach copy of Liability Insurance

How many years of debriefing experience do you have? __________

On last page please elaborate on some of your experiences.

Types of incidents you have responded to: please circle

explosions natural disasters

suicides robberies

robberies workplace accidents

domestic violence deaths

others

Do you presently work on a CISD team?

Yes No

Where did you receive your training in CISD?

How many members are on this team?

Are you able to “sign” or communicate effectively with hearing /sight impaired persons: Yes No

Please list any foreign languages that you speak, read or write.

Would you be interested in additional CISD training?

Yes No

Availability: Please give days & times of your availability.

Do you want to be contacted each time for availability check? Yes No

Business Reference:

Relationship: Client – Employer (please circle)

Name _____________________________________

Address ___________________________________

City/State/Zip ______________________________

Business Reference:

Relationship: Client – Employer (please circle)

Name _________________________________

Address _______________________________

City/State/Zip __________________________

Business Reference:

Relationship: Client – Employer (please circle)

Name _____________________________________

Address ___________________________________

City/State/Zip ______________________________

1. Please respond to each of the following questions (if you answer yes to any question, provide explanation and/or support documentation)

a) Have you ever had any professional license be revoked, suspended or limited?

( ) Yes ( ) No

b) Have you ever voluntarily surrendered your license?

( ) Yes ( ) No

c) Have you ever been convicted of a felony?

( ) Yes ( ) No

If yes, please provide county, state in which this occurred as well as details with outcome.

____________________________________________________________________________

d) Have you ever been denied professional liability insurance, or has your insurance ever been canceled or denied for renewal?

( ) Yes ( ) No

e) Have you ever been the subject of disciplinary proceeding by any professional association or organization?

( ) Yes ( ) No

f) Have you ever been the defendant in any lawsuit regarding your professional activities?

( ) Yes ( ) No

Please describe in some details some of your critical incident stress debriefing experiences:

Please enclose the following

Enclosed

1. Copy of your highest diploma _______

2. Proof of malpractice insurance, _______

Workers compensation or exemption

3. Copy of all licenses and/or certifications _______

4. Brief resume _______

5. Complete contractor questionnaire _______

6. Copy of your resume _______

7. List of contact phone numbers _______

In order you want contacted

SIGNATURE PAGE

By signing below I represent and warrant to Incident Management Team (IMT) that the information contained in the foregoing questionnaire is true and complete to the best of my knowledge and belief. I agree to immediately inform IMT if any material changes in such information occurs, whether before or after my entering into any contract with IMT including Critical Incident Stress Management Contractor. I understand that if any information is found to be untrue or changes occur, I can be denied inclusion or removed from the IMT Contractor list.

Printed Name

Signature (signature stamp not acceptable) Date Signed

Please either fax back to 877 501-8500 or snail mail to IMT, 1904 Orange Picker Rd. Jacksonville, Florida 32223