Indiana Crisis Assistance Response Team (I-CART)

Reference Form

An Affiliate of NOVA National Organization of Victim Assistance

I (applicant) _____________________________, waive the right to review this form and agree to its complete confidentiality.



_____________________________________ _______________________________
Applicant’s Signature                                               Date

The above named applicant is applying to be a member of I-CART. This team provides crisis response assistance and support to the community in case of a major trauma event or disaster. I-CART will be available to assist law enforcement agencies, fire departments, hospitals, and other emergency response agencies in responding to the mental health needs of victims during, immediately after and post trauma/disaster events. As you complete this application form, please keep in mind the involvement and responsibility that this person will undertake if accepted.

To assist us in the application process, we would appreciate your candid evaluation and specific comments regarding this applicant’s qualities. This form continues on the back. Your responses will be confidential and will not be shared with the applicant. This reference form will be used in conjunction with other recommendations and the individual’s formal application. If you have any questions about the nature of I-CART, please contact:

I-CART 317-596-2202                         www.i-cart.org

How long have you known the applicant and in what capacity?









Three strongest points:                                  Three possible limitations:
1.                                                                   1.

2.                                                                   2.

3.                                                                   3.

Limitations: Please circle any of these traits or tendencies that you have observed in the applicant:

Argumentative                Easily irritated                  Self-absorbed
Domineering                   Frequently depressed       Critical
Cocky                            Frequently worried            Sullen                                   Anxious                          Nervous or tense
Easily embarrassed         Impatient                         Joking sarcastic
Usually discouraged         Intolerant                        Low energy
Easily offended                Lacking in humor       

Doesn’t adapt to change/becomes anxious


Based on your understanding of I-CART and your knowledge of the applicant, please explain how you feel he/she would perform in such a position (continue on back if need additional room):






Do you recommend this individual as an I-CART Volunteer?

 Strongly recommend  Recommend   Recommend with reservations  Do not recommend



_________________________________________________ Signature and Date



_________________________________________________ Print Name

Your Contact Information:

Name

Phone Number

 Address

Email

Agency

Please return directly to: 

Indiana Crisis Assistance Response Team
Attn: Membership Files                                                                                           P.O. Box 44168
Indianapolis, IN 46244-0168