Checklist

Scope

This category audits the Psychological Health and Safety and Peer Support Program and Policy - Psychological Health and Safety: commitment and governance, the psychosocial hazard assessment, prevention and resilience training, the peer support team, the clinician network and assistance program, critical incident response, the after-the-call review as a mental health intervention, suicide prevention and post-vention, substance use and impairment, family program and chaplaincy, return to work after psychological injury, privacy, metrics including organizational psychological safety, and the accountability loop. It is Master Index category 11 items 11.1 to 11.6 and 11.8 (02 Audit Checklist Master Index). Harassment and violence (11.7) are scored in Checklist - Workplace Violence and Harassment; the learning firewall and the after-action review method in Checklist - Incident Reporting, Investigation and Learning.

Criteria

The criteria come from the National Standard of Canada for psychological health and safety in the workplace, its 13 psychosocial factors and its management-system cycle (CSA Z1003-13); its emergency-service model for paramedic organizations, used here as the closest published analogue (CSA Z1003.1:18); the guidance on managing psychosocial risk inside an occupational health and safety management system (ISO 45003:2021); the national peer support practice and training guidelines and the public safety personnel overlay (MHCC, 2013); (CIPSRT, n.d.); the evidence that single-session psychological debriefing is not supported (Rose et al., 2002)DOI; the impairment and work disability management standards (CSA Z1008:21; CSA Z1011:20); the applicable provincial or territorial occupational health and safety, workers’ compensation and privacy legislation (J28 Psychological Health and Safety; J32 Workers' Compensation and Firefighter Presumptions; J10 Privacy and Health Information; see Jurisdiction requirements); and the accreditation criteria on the assistance program, behavioural health screening and the annual appraisal (CPSE, 2019, criteria 11B.4, 11B.5, 11B.6).

Scoring

0 not in place. 1 documented, not implemented. 2 implemented, not verified effective. 3 implemented and effective with evidence. The category score is the mean of the item scores; report it by category. Score where the records live, the coverage and the interviews, not the policy. The auditor never reads peer contact content or clinical records; there should be none in department systems to read.

How to run this category

Read the signed policy, the committee charter and minutes, and the last psychosocial survey results and action plan.
Read the peer team charter, roster, training and supervision records; ask where the activity log is kept and who can reach it.
Read the critical incident procedure and the officer checklist; trace the last two activations in aggregate (time to first contact, dispatch included, review held).
Read the clinician list and the wait-time samples; read the assistance program contract for volunteers, families and addiction pathways.
Walk two stations and a dispatch position for crisis postings.
Interview a volunteer firefighter, a dispatcher, a company officer, a peer supporter and the clinical adviser.
Read the last two quarterly updates and the open items in the Corrective Action Register.

#	Item	Stage	Evidence expected
1	A psychological health and safety policy is signed by the fire chief and endorsed by the municipality, posted, and reviewed within 24 months, citing the National Standard and its emergency-service model	S1	Policy; signatures; posting observed (CSA Z1003-13); (CSA Z1003.1:18)
2	The policy and program state the distinction between psychological health (the member’s) and psychological safety (the organization’s condition), and commit to measuring both	S1	Policy clause 5.1; program section 5.1 (Edmondson, 1999)DOI
3	A joint committee (management, union, volunteer association, peer team lead, clinical adviser, dispatch) governs the program, meets at least quarterly, and reports to the JOHSC	S1	Charter; minutes; JOHSC record
4	A psychosocial hazard survey with a validated instrument was completed within 24 months, segmented by station, platoon, career and volunteer status and dispatch, reported at cell sizes of 10 or more	S1	Survey report (aggregate); instrument named (CSA Z1003-13)
5	Survey results were fed back to every station within 30 days and turned into an action plan with owners and dates; progress is in the quarterly update	S2	Feedback record; action plan; quarterly update
6	The department’s Z1003 self-assessment worksheet is completed with scores, evidence and actions for all 13 factors and the operational exposures	S2	Worksheet in the appraisal (CSA Z1003-13); (CSA Z1003.1:18)
7	At least 90 per cent of members, including volunteers and dispatch, completed a recognized first-responder mental health literacy and resilience program within three years; officers completed the leader module, psychological first aid and learning-review facilitation	S2 (S1 for the first cohorts)	Training records by segment. Score 2 at 75 to 89; 1 below 75
8	Suicide awareness training is completed by all members and gatekeeper training by peer supporters and officers	S2	Training records
9	The peer support team is selected by written criteria with an interview that includes a labour or association representative, a signed confidentiality agreement and a probationary year; popularity is not a criterion	S1	Selection criteria; interview records (aggregate); agreements signed
10	Peer supporters hold a core course of at least two days aligned with the national guidelines, suicide intervention training and an annual refresher	S1	Certificates; refresher dates (MHCC, 2013); (CIPSRT, n.d.)
11	A clinical adviser with first-responder competence supervises the team at least quarterly in group and on request individually, with debriefs after heavy activations	S1	Supervision log; adviser named by role. Score 0 if the team has no clinical supervision
12	Coverage: every platoon, district, volunteer station and dispatch has a peer supporter reachable 24 hours a day through a duty phone or dispatch, and the team is never fewer than six	S1	Roster; coverage table; monthly test-call log
13	Scope and confidentiality limits (imminent risk, abuse of a child or vulnerable person, court order, written consent) are written in the charter and told to every member at the start of every contact	S1	Charter; peer supporter interview; member interview
14	Peer support records contain counts and types only, no names and no content, and are held by the team lead outside the human resources and records management systems	S1	Ask to see where the log lives and who has access; HR and RMS searched for peer records. Score 0 if any peer record is found in HR or the RMS
15	The aggregate activity log is reported monthly to the program manager and quarterly to the senior team and the JOHSC, with cells below 10 combined	S2	Form - Peer Support Activity Log (Aggregate); quarterly update
16	A pre-vetted clinician network with first-responder competence is published to members and the median wait to first appointment is five business days or fewer	S1	Clinician list; quarterly wait-time sample. Score 2 at six to 10 days; 1 above 10
17	The assistance program contract covers members, volunteers and families, allows a course of treatment, includes addiction pathways, and reports utilization in aggregate	S1	Contract clauses; provider aggregate report. Score 0 if volunteers are excluded
18	The critical incident procedure offers a crew welfare check, peer contact within 24 hours, an optional group session at three to seven days, individual referral and follow-up at two to four weeks, includes dispatchers, and states that attendance is voluntary and that mandatory single-session debriefing is not used	S1	Procedure text; officer checklist in cabs. Score 0 if any policy mandates debriefing (Rose et al., 2002)DOI
19	The last two activations show time to first peer contact within 24 hours, dispatch included, and the follow-up done	S2	Activation rows in the aggregate log; dispatch supervisor interview
20	Company officers hold a short, non-blaming after-the-call review within 24 to 72 hours of significant calls (80 per cent or more of working fires and serious calls), separate from discipline, and are trained to hand off to peer support when distress surfaces	S1	Officer logs; training records; Checklist - Incident Reporting, Investigation and Learning
21	A suicide prevention and post-vention protocol exists, has been exercised within 24 months, and crisis contacts (provincial line and 9-8-8) are posted at every station, in every cab, at dispatch and on peer cards	S1	Protocol; exercise record; postings observed at two stations and dispatch
22	Substance use is treated as a health matter with a confidential pathway and protection from discipline for seeking help; impairment at work is managed as a separate safety matter on management-system principles, and the member is told which path they are on	S2 (S1 for the EFAP addiction pathway)	Policy text; impairment procedure (CSA Z1008:21); interviews
23	A family orientation is held at recruit graduation and annually; families have assistance program access; chaplains, where present, have terms of reference within the peer team’s confidentiality rules	S2	Orientation records; contract; terms of reference
24	A line-of-duty-death family support plan exists with the national foundation and memorial grant information current	S2	Plan; review date
25	Psychological injury return to work follows the same graduated system as physical injury, planned with the treating clinician; the last three cases (aggregate) show graduated return	S2	Aggregate case summary; coordinator interview (CSA Z1011:20)
26	A written information-sharing protocol with clinicians and the assistance provider names what crosses to the department (fitness determination, imminent risk, written consent) and nothing else	S1	Protocol signed; HSO interview; see Policy - Records, Privacy and Health Information
27	Members and survivors are supported in workers’ compensation claims for psychological injury, including the presumption where the law provides it	S1	Navigator process; aggregate claim counts (J32 Workers' Compensation and Firefighter Presumptions)
28	Indicators 1 to 13 of the program are reported quarterly in aggregate, including the learning-system measures used as psychological safety measures with their “what it is not” disclaimer carried over	S2	Quarterly indicator worksheet; disclaimer present (The Human Factor, 2026h)
29	A learning-team session with members, volunteers and dispatchers was held before the peer procedures, the critical incident response or the after-the-call review were written or last changed	S2	Session write-up without names; revision history (Hollnagel, 2014); (Conklin, 2012)
30	The just-culture line is written and known: nothing said in learning reviews, learning teams or peer contacts is used for discipline; conduct concerns go to a separate process and the member is told which process they are in	S1	Policy clause 5.8; interviews (Dekker, 2016)
31	Accountability and closed feedback loop. The program’s table names one owner (fire chief through a deputy chief and the program manager, with the fire chief personally owning stigma reduction), doers, verifiers with frequency (clinical adviser quarterly, HSO, JOHSC, audit annually), feedback paths with cycle times, and the closure rule with escalation on the register’s priority scale	S1	Table filled with roles; register entries; one closed item traced to evidence
32	Member’s concern route. A concern is logged the same day without content and answered within 10 working days; a concern about an officer’s behaviour goes to that officer’s supervisor; anonymous concerns are answered in the twice-yearly note	S1	Concern log (counts); answer dates; interview the last two members who raised one
33	Psychological safety (organizational). Members report they can tell their officer a call got to them or that they are not right to go back on the truck, without it being a story at the next shift; near-miss and good-catch reports per 100 incidents are rising; the learning-system measures for reporting and for the firewall are tracked	S2	Survey item; near-miss rate; readiness self-assessment parts 1 and 4 (Edmondson, 1999)DOI; (The Human Factor, 2026h)
34	Leaders model the program: the fire chief and officers attended the resilience training with the crews, use the supports and say so, and answer concerns within 10 working days with what changed	S2	Training records (chief officers); interviews; twice-yearly notes
35	The program feeds the learning system: any suicide or attempt, psychological injury claim, critical incident activation or harassment finding is reviewed at Tier 2 as a system event without identifying detail; a line-of-duty death is Tier 3; significant calls get the Tier 1 review with the two welfare questions asked separately	S2	Triage log; AAR records; Incident Investigation and Learning Program
36	The Stage 1 minimum is funded: peer training and supervision, clinical adviser, assistance program for volunteers and families, resilience training, survey, postings, program manager and team lead time	S1	Budget worksheet; program appraisal
37	Dispatchers, mechanics, investigators and administrative staff are inside every element (training, peer coverage, critical incident inclusion, survey)	S1	Records by segment; dispatcher interview. Score 0 if dispatch is outside the critical incident procedure
38	An annual program evaluation with aggregate metrics has gone to the fire chief’s management review and the JOHSC	S2	Evaluation; JOHSC minutes
39	Accreditation crosswalk (where applicable): an assistance program with timely access to critical incident stress support, peer support, counselling and other behavioural health resources, met with evidence-based voluntary options; behavioural health screening through the medical; annual appraisal	S2	Evidence above mapped to (CPSE, 2019, criteria 11B.4, 11B.5, 11B.6)

Effectiveness questions (observation or interview only)

Ask a dispatcher what happened after the last fatal call they took: who checked on them, when, and whether anyone from the fire side included them. Compare with the activation log.
Ask a peer supporter where they keep their notes and what they would do if a member told them something that worried them. Listen for the four limits and for “nothing with a name goes anywhere”.
Ask a company officer to describe the last after-the-call review they ran and what they would say if a member said “that one got to me” in the middle of it.

Category result

Items scored	Mean score	Items at 0 or 1	Open corrective actions	Auditor (role)	Date

Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

Topic	What to check in your jurisdiction	Page
Privacy and Health Information	Whether the department’s clinicians and the assistance provider are custodians under a health information statute, and which access-to-information and privacy statute governs the department’s own records (items 14, 26)	J10 Privacy and Health Information
Workplace Violence	Whether a workplace violence regulation applies to the department and what its risk assessment and prevention plan must contain (scored in the Workplace Violence and Harassment category)	J26 Workplace Violence
Workplace Harassment	Whether a harassment prevention policy is required and what it must cover: reporting, investigation, training and review (scored in the Workplace Violence and Harassment category)	J27 Workplace Harassment
Psychological Health and Safety	Whether the OHS statute counts psychological health as part of health and safety, and the crisis line and publicly funded supports for public safety personnel to post and list (items 16, 21)	J28 Psychological Health and Safety
Workers’ Compensation and Firefighter Presumptions	Whether a PTSD or psychological injury presumption covers career and volunteer firefighters and dispatchers, the diagnosis it needs and the claim window (item 27)	J32 Workers' Compensation and Firefighter Presumptions

References

Canadian Institute for Public Safety Research and Treatment [CIPSRT]. (n.d.). Resources for public safety personnel: Peer support guidelines, moral injury guide and PSPNET [Web page]. https://www.cipsrt-icrtsp.ca/en/

Center for Public Safety Excellence [CPSE]. (2019). Fire and emergency service self-assessment manual (10th ed.). Commission on Fire Accreditation International. https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf

Conklin, T. (2012). Pre-accident investigations: An introduction to organizational safety. Ashgate.

CSA Group. (2013). CAN/CSA-Z1003-13/BNQ 9700-803/2013 (R2022), Psychological health and safety in the workplace: Prevention, promotion, and guidance to staged implementation (free to read from CSA Group and the Mental Health Commission of Canada). https://www.csagroup.org/store/product/CAN-CSA-Z1003-13-BNQ%209700-803-2013/

CSA Group. (2018). CSA Z1003.1:18 (R2025), Psychological health and safety in the paramedic service organization. https://www.csagroup.org/store/product/2704398/

CSA Group. (2020). CSA Z1011:20 (R2024), Work disability management system. https://www.csagroup.org/store/product/CSA%20Z1011:20/

CSA Group. (2021). CSA Z1008:21, Management of impairment in the workplace. https://www.techstreet.com/standards/csa-z1008-21?product_id=2221471

Dekker, S. (2016). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press.

Edmondson, A. C. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. doi:10.2307/2666999

Hollnagel, E. (2014). Safety-I and Safety-II: The past and future of safety management. Ashgate.

International Organization for Standardization. (2021). ISO 45003:2021, Occupational health and safety management: Psychological health and safety at work: Guidelines for managing psychosocial risks. https://www.iso.org/standard/64283.html

Mental Health Commission of Canada [MHCC]. (2013). Guidelines for the practice and training of peer support. https://www.mentalhealthcommission.ca/wp-content/uploads/2021/09/Guidelines-for-the-Practice-and-Training-of-Peer-Support.pdf

Rose, S., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, (2), Article CD000560. doi:10.1002/14651858.CD000560

The Human Factor. (2026h). NextCall Readiness Index: Construct map and limits [Unpublished instrument note].