Indiana Crisis Assistance Response Team (I-CART)
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:
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:
Please return directly to:
Indiana Crisis Assistance Response Team
Attn: Membership Files P.O. Box 44168
Indianapolis, IN 46244-0168