Please acknowledge you have read the above notice and agree with it before filling in this form: Please acknowledge you have read the above notice and agree with it before filling in this form: I Agree

Your First Name*

Your Family Name*

Your relationship to the team on whose behalf you are applying*

Your location (City & Country)*

Your Email Address*

Your telephone we can reach you on now*

We realize that it can sometimes be difficult to give us some of these details, but please give us as much as possible from this list in the big box below. This will help us determine where and when are the best options for debriefing. We realize that it can sometimes be difficult to give us some of these details, but please give us as much as possible from this list in the big box below. This will help us determine where and when are the best options for debriefing. Team name and/or organization Number of people on the team that need debriefing Where the team has been working (country or region) Where the team is located now (if they have evacuated)

Team information:*

Contact person in the organization (if appropriate)

Their email address

What happened? Give us a brief overview of the incident, when and where it happened, who was involved and your role in it. Check off each box to be sure you have covered everything in in your explanation in the big box below. What happened? Give us a brief overview of the incident, when and where it happened, who was involved and your role in it. Check off each box to be sure you have covered everything in in your explanation in the big box below. What happened? When did it happen? Where did it happen? Who was involved? Your role in it.

Use as much space as you need to explain.*

Did you take part in a structured defusion immediately after the incident?* Did you take part in a structured defusion immediately after the incident?* Yes No

Tell us what it looked like.*

Anything else you'd like to tell us at this point?

Preferred language for debriefing - 1st choice Preferred language for debriefing - 1st choiceEnglishFrenchDutchGermanSwiss German

Preferred language for debriefing - 2nd choice Preferred language for debriefing - 2nd choiceSame as first choiceEnglishFrenchDutchGermanSwiss German