REST Approved Forms v6.0 (Public)

Palmerston North’s Rescue Emergency Support Team – Approved Forms v5.
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Palmerston North’s Rescue Emergency Support Team – Approved Forms v6.0c
TABLE OF CONTENTS ............................................................................................................................................... 2

RESCUE EMERGENCY SUPPORT TEAM APPLICATION FORM..................................................................... 3
INTERVIEW SHEET .................................................................................................................................................... 7
PERSONAL EVALUATION FORM.......................................................................................................................... 15
PERSONAL ACTIVITY LOG .................................................................................................................................... 19
TEAM ACTIVITY LOG.............................................................................................................................................. 21
ATTENDANCE REGISTER ....................................................................................................................................... 23
DESC DEBRIEF FORM .............................................................................................................................................. 25
TARGET INCIDENT PLANNING SYSTEM (TIPS) ........................................................................................... 27
SITUATION REPORT ................................................................................................................................................ 29
LOAN FORM................................................................................................................................................................ 31
PATIENT REPORT FORM ........................................................................................................................................ 33
REQUISITION FORM ................................................................................................................................................ 35
REGISTER OR NOTIFICATION OF ACCIDENT OR SERIOUS HARM .......................................................... 37
MEETING MINUTES ................................................................................................................................................. 39
PERSONAL KIT ISSUE .............................................................................................................................................. 43
COMMISSIONING FORM ......................................................................................................................................... 45
EQUIPMENT SERVICE LOG ................................................................................................................................... 47
EQUIPMENT SERVICE LOG ................................................................................................................................... 50
RISK MANAGEMENT FORM .................................................................................................................................. 51
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Return completed form to:

Emergency Management Officer (Rescue)
Private Bag 11034,
Palmerston North
This information is held for the purpose of assessing your suitability as a team member. You have
the right to access personal information and to seek any correction you think necessary to ensure
accuracy.
Please Print
Personal details
Name (full name): Date of Birth:
Address (residential):
Home phone: Work phone: Cell phone:
Primary email:
NZQA number (if applicable): Drivers Licence number (if held):
Classes/endorsements:
Employment details
Company name: Managers Name:
Occupation:
Address (postal):
Managers work phone: Managers cell Phone (if avail): Office fax:
Managers email:
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Next of kin (NOK) details

Name (full name): Relationship:
Address (residential):
NOK home phone: NOK work phone: NOK cell phone:
Medical Record
List any allergies, medical conditions, contagious illnesses or injuries you have, or have had:
List any medication you are currently taking or take regularly:
Special needs
Do you have any special needs that we should be aware of?
Dietary requirements
Do you have any special dietary requirements?
Criminal Record
List any charges or convictions for criminal offences; including Police diversion, or any charges
pending, excluding those covered by the Criminal Records (Clean Slate) Act 2004:
(note: Criminal convictions are assessed on a case by case basis and may not exclude you from applying)
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Experience
Please list your experience and/or qualifications in the following areas:
Medical / First Aid:
Rescue / Emergency Services:
Climbing / Rope skills:
Water Skills:
List any relevant cultural and/or linguistic skills you may have:
What other skills do you bring to the team?
What do you want to get out of joining the Team?
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Personality
What is your main strength?
What is your main weakness?
Do you have any phobias (fear of heights, darkness, water etc)?
How would YOU describe yourself in five words or less?
Are you prepared to attend a residential weekend Recruits Course if required (circle): Y / N
How did you hear about the Rescue Emergency Support Team?
Is there any comments or information that you would like to provide below?
I ______________________________________ certify that the above information is true and correct;

that I have not omitted any information that may affect my application, and that I am medically and
physically fit for operational duties.
_________________________________ _____________________
Signed by Applicant Date
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Applicant
Panel
Date/Time
 Welcome
 Introductions
 Format & scope of interview
 Photo
 Run through application – discuss queries and discrepancies
 Weighted questioning
 Invite questions from applicant
 Thank applicant for attending
Membership application – queries and discrepancies
Photo No.
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Interview Summary: one summary per applicant
Panel Discounters
Average %
Total score:  Panel Average Score below  Conflict of interest – external
60% party
 Criminal History  Insufficient teamwork experience
 Incompatible physically (eg  Insufficient commitment
/ 140 x 100 = injury/ability)  Voluntary Withdrawal
 Incompatible Phobias (eg
heights/water)
 Other/notes:
Team Meeting Result:
Choice Notes
□ YES
□ NO
 Unsuccessful
 Accepted
Notification:
Applicant notified by ________________________ on ______/_______/________
Application process verified:
______________________ _______/______/_______
Rescue Manager Signature Date
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Score
Weighted questioning: Applicant: ________________________
Interviewer: _______________________
Scoring
0: Unable to answer question or answer not relevant to question
1: Totally unacceptable answer, not compatible with team structure, ethos or culture
2: Unsatisfactory or below what you would expect an average answer would be.
3: Satisfactory / good answer
4: Really good answer, exceeded what would be expect from the average person
5: Brilliant answer, perfect compatibility with team structure, ethos or culture
NB: ½ scoring is acceptable, i.e. you could have 3.5 as a score
Availability
Score of 5:
Q: If you were called to go to a rescue out of town on short notice for up to 4 days,
what things would you need to organise before you could go?
(Rational: Due to the nature of rescue we often have no warning of when we will be
called)
Notes:
Motivation
Score of 5:
Q: Why did you apply to join the team and what do you hope to gain from being a
member?
(Rational: members have many different reason for joining the team, knowing the
reasons why makes it easier to motivate them to achieve their goals)
Notes:
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Commitment
Score of 5:
Q: What sacrifices or changes would you have to make to be able to attend
weekend training and courses?
(Rational: Course are often on the weekend and members must undertake
additional training in their own time)
Notes:
Discipline
Score of 5:
Q: Most people have been asked to do things they didn’t really want to by a boss or
an authority figure. Tell us about a time when this has happened to you, and how
you handled it.
(Rational: Rescue environments sometime require a strict non-negotiable command

style)
Notes:
Team work
Score of 5:
Q: If you noticed a colleague or friend was looking sad or depressed, how would
you approach them and what would you do?
(Rational: Things don’t always go well and sometimes there will be issues,
members need to be comfortable offering assistance and providing welfare to other
members)
Notes:
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Organisation & Administration

Score of 5:
Q: What administration and organisational skills or experience can you bring into
the team?
(Rational: The backbone to any organisation and the success it receives is from
effective administration and the organisational procedures.
Notes:
Rescue & Technical

Score of 5:
Q: Although the team provides all technical rescue training, do you have any rescue
or emergency skills or experience can you bring into the team?
(Rational: Previous experience can sometimes make it harder to learn new ways,
however sometimes these skills may also benefit the team)
Notes:
Availability
Score of 5:
Q: If you were called to a rescue in the middle of a weekday, what impact would
that have on your employment?
(Rational: Daytime crewing is the hardest to maintain, members must consider

whether they are realistically able to provide a response during weekdays)
Notes:
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Stress
Score of 5:
Q: Have you ever been in a stressful situation, if so what was it and how did you
deal with it? (If not how do you think you would cope in a stressful environment?)
(Rational: A rescue environment can lead to various forms of stress, members must
be able to recognise stress and manage it)
Notes:
Political Correctness
Score of 5:
Q: What sort of humour do you find distasteful and why?
(Rational: The team often relieve stress through the use of humour, which is not
always politically correct, members must be comfortable in such an environment)
Notes:
Social
Score of 5:
Q: If you were asked to organise a social activity for a group people with a wide
range of backgrounds and interest, what kind of activities would you suggest?
(Rational: The team needs to have a close team bond, and we endeavour to have a
social element outside training times)
Notes:
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Conflict Resolution
Score of 5:
Q: tell us about a situation where you have asked someone to carry out a task, and
it hasn’t happened and how you handled the situation?
(Rational: The team must be able to resolve issues and conflicts within itself before
they become bigger issues)
Notes:
Additional skills
Score of 5:
Q: What unique skills do you have that you would bring to the team?
(Rational: One of the strengths of the team, is the diversity of skills of the members)
Notes:
Interest
Score of 5:
Q: What do you know about Civil Defence and the Palmerston North Rescue
Emergency Support Team?
(Rational: Members should understand what they are becoming involved in and the
commitment they are taking on)
Notes:
Observations and opinion:
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Name:
Introduction
The purpose of the Personal Evaluation is to provide a fair, consistent and structured method of
providing feedback to all team members.
Regular feedback allows members to gauge how they are progressing with their personal
development within the team. It allows any minor issues to be addressed before they become major
issues and therefore allowing the member to take their own necessary measures before the Rescue
Manager has to intervene.
Each member has the opportunity to give feedback to the Rescue Manager, providing an open, two
way process.
Review Period
The review period specifies the dates the Personal Evaluation covers. The end date will almost
always be prior to the actual date the evaluation is given to the team member; therefore any matters
arising after the date listed below is held till the next evaluation.
Review Period: 12 September 2009 – 27 September 2010
Attendance
Attendance at weekly training is an important part of being a team member. It enables members the
opportunity to keep their skills current and ensures other members are comfortable working with them
during high risk and stressful activities.
Note: the period for attendance is from 1 January 2010, not 12 September 2009.
Training Attendance:
Description % of activities eligible

Training attendance %
Event attendance %
Incident attendance %
Total hours
40 hour week equivalent
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Qualifications Attained
All team members are encouraged to continue to develop themselves, both in technical matters as
well as in personal areas. This growth or Personal Role Development keeps the team progressing
while providing a structured plan for individuals to archive goals and qualifications that can often be
used outside of team activities.
Standards and qualifications:
Standards and qualifications Date achieved
Performance
Each of the four indicators Attitude, Interaction, Involvement and Technical Ability broadly assess
separate parts of being a team member. No one member is expected to excel in all areas; each
member brings their own strengths and weaknesses to the team, thus complementing other team
member’s strengths and weaknesses.
Attitude
Unacceptable Improvement Average Above Average Excellent
Feedback:
Attitude is measured on how a member reacts to situations they are faced with, how they deal with
commands and instructions from people they report to and general contribution towards positive team
dynamics.
Interaction
Feedback:
Interaction reflects how well a member interacts with other members of the team; the public and
other people or teams they come in contact with.
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Involvement
Feedback:
Involvement or ownership is based on a member’s attendance at scheduled and optional trainings

as well as any additional support they provide over and above their qualification requirements.
Technical Ability
Feedback:
Technical Ability highlights how well a member performs tasks or activities required of them at their
current qualification level. A member would not receive an adverse evaluation should they not be able
to perform tasks outside of their current qualification, however the may receive a positive evaluation if
they can.
Targets / Goals
All team members are encouraged to continually develop their knowledge and skills. Having targets
or goals written down will assist members in actualising them and further their Personal Role
Development.
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General notes
Date of Evaluation feedback:
Position Name (print) Sign Date

Team Member
Rescue Manager
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Date: Time:
Location:
Weather: Height or Flow
Duration: Reference:
Activity: □ Technical rope □ Swiftwater □ Land SAR

□ Flood □ Rural fire □ USAR/GR
□ Medical □ Welfare □ Helicopter
□ Other (specify):
Type: □ Training □ Exercise □ Assessment □ Operation
□ Skills Maintenance □ Public display □ Group presentation
Role:
Group size: Staff no: Others no: Student no:
Configuration/Notes/Teaching Points (Additional information can be added to the reverse of this form.)
Members Signature: __________________________________________
Duty Team Leader Signature: ___________________________________
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Further information
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Date: Alerted:
Incident: Enroute:
Controller: At incident:
Duty EMO: Stood Down:
DTL: At Base:
Safety Officer: Completed:
Location (ref): Height or Flow

Weather: Reference:
Activity: □ Technical rope □ Swiftwater □ Land SAR

□ Flood □ Rural fire □ USAR/GR
□ Medical □ Welfare □ Helicopter
Type: □ Training □ Exercise □ Assessment □ Operation
□ Skills Maintenance □ Revalidation □ Presentation
Vehicles used: □ C85 □ C83 □ Trailer □ Other:

Attachments: □ CIMS Forms □ Pt Report(s) □ WX Report □ RAMS □ ACC
Has all equipment (including ropes) been cleaned, serviced and returned? □ Yes □ No
List any cache damaged or out of service (advise EMO or RM within 24 hours, tag and remove from service):
Configuration/Notes/Teaching Points (Additional information can be added to the reverse of this form.)
Duty Team Leaders Comments
DTL Signature: __________________________________________
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Further information
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Palmerston North’s Rescue Emergency Support Team – Approved Forms v5.7
Ref
Start Date: ____________________
Topic
End Date: ____________________
Names D/M
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
P (Present), Pa (Present – But late with apology), L (Late), A (Apology), X (Absent without excuse), V (Leave), - (Attendance not required).
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Describe action Example Suggestion Consequence

Improvements
Describe action Example Suggestion Consequence

Well Done
• Be honest with yourself and others. • Be supportive of each other. • Be sensitive to the needs of others.
• Speak for yourself. Own your statements. • Listen to, and respect others viewpoints. • Give your best.
• Avoid put downs, including yourself. • Be responsible for your own comfort. • Be opened minded.
• Maintain confidentiality. • Keep a sense of humour. • No justifications.
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© Emergency Management Academy of New Zealand. Used with permission.
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(Additional information can be added to the reverse of this form.)
Name: Position:
Date: Time:
Location:
Situation (since last SitRep or briefing. Changes in the event itself, people and property
affected, actions taken, weather, etc)
Logistics (Resource requests, access & assembly, command & communication changes)
Other (any other important information not already covered)
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Further information
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Date of use: Start / End Time:

Location:
Loanee: Contact Ph:

Return Date: Return Time:
Date Applied: Approved by:
DTL Notified: □ Yes □ No Vehicle Booked: □ Yes □ No
Cache
Loaned:
Purpose:
Conditions
Of Use:
Short Notice: □ Yes □ No Notification Method:

Out of Area: □ Yes □ No Approved By:
Person in charge:
Relevant Qualification(s):
Approval Signature: ___________________________________________
Returned Date: Returned Time:
Has all equipment been returned, cleaned & serviced? □ Yes □ No
List any cache damaged or out of service (advise EMO or RM within 24 hours, tag and remove from service):
Loanee Signature: __________________________________________
Duty Team Leader Signature: ___________________________________
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The information contained in this report is medically privileged and confidential. Upon completion the original shall accompany the patient,
with a copy if possible to be filed with the Team Activity Log.
Patient Name Patient DOB
/ /
Incident Location/CAD Ref# Patient Age
Patient Gender
Male / Female
Chief Complaint First Aider or Qualification (tick)

Medic Name First Aid PHEC Other (Specify)
1
2
3
4
Patient Assessment Time Pulse Respirations LOC
AVPU
AVPU
AVPU
AVPU
AVPU
AVPU
Patient – Previous Illness
 Nil  Epilepsy  Respiratory
 Asthma  High Blood Pressure  Stroke (CVA/TIA)
 Cardiac  Psychiatric  Unknown
 Diabetes  Kidney (Renal)  Other (Specify)
Patient – Other Information Times 24 Hr Format
Last Meal / Drink: Incident/Onset
Allergies: Patient Access
Current Medications: Patient Stabilised
Patient Handed Over
Outcome
 Refused Treatment  Handed over to Doctor
 Patient to see own Dr  First aid at scene only
 Handed over to Ambulance  Other (specify)
Signature Print name Date
First Aider / Medic
Patient
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Further information
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This requisition may only be exercised during a declared state of emergency under the Civil Defence
Emergency Management Act 2002. Persons making the requisition shall provide proof of identity
pursuant to section 93 of the Civil Defence Emergency Management Act 2002 if requested.
Requisitioned From (Name & Address) Duty Team Leader
Declared Emergency Description
CDEM Group
This is to confirm the following land, building, vehicle, animal, boat, apparatus, implement, earth-moving
equipment, construction materials or equipment, furniture, bedding, food, medicines, medical supplies, or any
other equipment, materials have been requisitioned under the Civil Defence Emergency Management Act 2002.
The above requisitioned property is under the control of:
Signed:
Designation:
Date:
Time:
For further information contact your local Civil Defence Emergency Operations Centre.
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Further information
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1 Particulars of person completing this form: 11 Agency of accident/ serious harm:

(agency, name, postal address and telephone number)  machinery or (mainly) fixed plant
 mobile plant or transport
 powered equipment, tool, or appliance
 non-powered handtool, appliance, or equipment
 chemical or chemical product
 material or substance
2 The person reporting is a:  environmental exposure (e.g. dust, gas)
 Team member  PNCC employee  Other  animal, human or biological (other than bacteria or virus)
3 Location of place of work:  bacteria or virus
12 Body part:
 head  neck  trunk  upper limb  lower limb
 multiple locations  systemic internal organs
4 Personal data of injured person:
13 Nature of injury or disease:(specify all)
Name
 fatal
Residential  fracture of spine  puncture wound
address  other fracture  poisoning or toxic effects
 dislocation  multiple injuries
 sprain or strain  damage to artificial aid
Date of birth Sex (M/F)  head injury  disease, nervous system
 internal injury of trunk  disease, musculoskeletal
5 Role or job title of injured person: system
(team members and PNCC employees only)  amputation  disease, skin
 open wound  disease, digestive system
 superficial injury  disease, infectious or
6 The injured person is: parasitic
 Team member  PNCC employee  bruising or crushing  disease, respiratory system
 External agency  Other  foreign body  disease, circulatory system
 burns  tumour (malignant or benign)
7 Period of service of injured person:  nerves or spinal chord  mental disorder
(team members and PNCC employees only)
 1st week  1st month  1-6 months 14 Where & how did the accident/serious harm happen?
 6 months-1 year  1-5 years  Over 5 years (Additional information can be added to the reverse of this form.)
 non-team or employee
8 Treatment of injury:
 None  First aid only
 Doctor but no hospitalisation  Hospitalisation
9 Time and date of accident/ serious harm:

Time am/pm
Date
15 If notification from a PNCC employee, the RM or DTL:
Hours worked since arrival at activity (a) Has an investigation been carried out?  yes  no
(team members and PNCC employees only) (b) Was a significant hazard involved?  yes  no
10 Mechanism of accident/ serious harm:
 fall, trip or slip  hitting objects with part of the body Signature and date __________ ___ / ___ / ___
 sound or pressure  being hit by moving objects
 body stressing  heat, radiation or energy
 biological factors  chemicals or other substances Name and
 mental stress position
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Further information
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Location:
Date: Time:
Present:
Apologies:
□ Read:
Previous
Minutes:
□ Seconded:
Matters Arising
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Rescue Manager
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Training Officer
Equipment Officer
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Social Coordinator
General Business
Meeting closed:
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Members name: Date:

Description of
Equipment:
(only one item per form)
Model:
Size:
Serial number:
Expiry:
Reason for
issue:
Members
Date:
signature:
Authorised
Position
persons name:
Authorised
Date:
signature:
Authorised use only
Reason for end □ Expired □ Damaged □ Lost

of issue:
□ Stolen □ No longer required □ Changed requirements
□ Returned (left team) □ Other (specify):
Description:
Authorised
Position
persons name:
Authorised
Date:
signature:
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All equipment shall be commissioned and entered in to the commissioning database, once in service
its history is monitored via the equipment maintenance logs.
Equipment should be entered directly into the database, however in cases where this is not possible
or practical; the following form should be completed and given to the Equipment Officer for addition.
Date in: Identifier (DSN):

Description:
Specifications (Size, length, material, MBS):
Standards (NFPA, CE, EN, AS/NZ):
Weight (g):
Manufacture: Mnf. Number:
Supplier: Order Number
Cost: Due Out:
Cache type: □ Rope □ Swiftwater □ USAR □ General
Date in: Identifier (DSN):

Description:
Specifications (Size, length, material, MBS):
Standards (NFPA, CE, EN, AS/NZ):
Weight (g):
Manufacture: Mnf. Number:
Supplier: Order Number
Cost: Due Out:
Cache type: □ Rope □ Swiftwater □ USAR □ General
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Date: Reference:
Activity:
Location
Person in
charge:
Reported by
Item* DSN:
Reason for
service
Has equipment been tagged and removed from service? □ Yes □ No
Has DTL tor RM been notifed? □ Yes □ No
Has Team been notifed of removed equipment? □ Yes □ No □ NA
Authorised use only
Action taken: □ Checked OK, retuned to service □ Monitoring in service

□ Repaired □ Decommissioned
Description of
action taken:
Authorised
Position
persons name:
Authorised
Date:
signature:
Has Team been notifed of outcome? □ Yes □ No
(Completed forms are to go to the back of the folder)

*One form per item
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The DTL is to be advised of any equipment issues. Damaged equipment must be tagged and removed from service immediately. The Team should be advised before the debrief or at the next team activity.
Tick
Date Reference / Activity DSN and description Damage / Notes Initial
R* D*
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* R = returned to service, D = Decommissioned. This should only be ticked by the RM, DTL or Equipment Officer unless otherwise authorised. The Team should be notified at the next team activity.
1 5
Risks (potential
losses/ incidents)
2 6
3 7
4 8
Causal Factors Risk Reduction Strategies

Skills, attitude, age, fitness, ratios, experience, health etc
People
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Clothing, shelter, transport, activity specific gear, safety gear etc
Equipment
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Weather, terrain, water, season etc
Environment
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Emergency Protocol
Emergency procedures to manage each risk identified on the top of page one Emergency gear required
1
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Staffing Requirements/Qualifications Standards and Guidelines applicable
Final approval: Rescue Manager Final approval: Person in charge
Sign Acceptance Sign Acceptance

Comments: Person in charge has the power to cease operations at any time if any of the risk reduction strategies cannot be met.
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Palmerston North’s Rescue Emergency Support Team – Approved Forms v5.

TABLE OF CONTENTS ............................................................................................................................................... 2

Return completed form to:

Home phone: Work phone: Cell phone:

NZQA number (if applicable): Drivers Licence number (if held):

Next of kin (NOK) details

NOK home phone: NOK work phone: NOK cell phone:

List any medication you are currently taking or take regularly:

Medical / First Aid:

Rescue / Emergency Services:

Climbing / Rope skills:

What other skills do you bring to the team?

What do you want to get out of joining the Team?

What is your main weakness?

Do you have any phobias (fear of heights, darkness, water etc)?

How would YOU describe yourself in five words or less?

I ______________________________________ certify that the above information is true and correct;

Membership application – queries and discrepancies

Interview Summary: one summary per applicant

Team Meeting Result:

Applicant notified by ________________________ on ______/_______/________

Application process verified:

(Rational: Rescue environments sometime require a strict non-negotiable command

Organisation & Administration

Rescue & Technical

(Rational: Daytime crewing is the hardest to maintain, members must consider

Observations and opinion:

(This page intentionally left blank)

Review Period: 12 September 2009 – 27 September 2010

Description % of activities eligible

Standards and qualifications:

Standards and qualifications Date achieved

Involvement or ownership is based on a member’s attendance at scheduled and optional trainings

Date of Evaluation feedback:

Position Name (print) Sign Date

Activity: □ Technical rope □ Swiftwater □ Land SAR

Members Signature: __________________________________________

Duty Team Leader Signature: ___________________________________

Location (ref): Height or Flow

Activity: □ Technical rope □ Swiftwater □ Land SAR

Vehicles used: □ C85 □ C83 □ Trailer □ Other:

Duty Team Leaders Comments

DTL Signature: __________________________________________

Start Date: ____________________

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Describe action Example Suggestion Consequence

Describe action Example Suggestion Consequence

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© Emergency Management Academy of New Zealand. Used with permission.

(This page intentionally left blank)

(Additional information can be added to the reverse of this form.)

Other (any other important information not already covered)

Date of use: Start / End Time:

Loanee: Contact Ph:

Short Notice: □ Yes □ No Notification Method:

Approval Signature: ___________________________________________

Returned Date: Returned Time:

Has all equipment been returned, cleaned & serviced? □ Yes □ No

Loanee Signature: __________________________________________

Duty Team Leader Signature: ___________________________________

(This page intentionally left blank)

Patient Name Patient DOB

Incident Location/CAD Ref# Patient Age

Applicant notified by ____________________ on /_/____