Form
Form - Peer Support Activity Log (Aggregate)
Document FSSMS-FRM-25Stage 1Revision 4Version 0.3.3
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Purpose. The only record of peer support activity the department holds: counts, types and timings, with no names and no content, so that the program can show reach and responsiveness without anyone being identifiable (MHCC, 2013); (CIPSRT, n.d.). The peer team lead keeps it outside the human resources and records management systems and reports it monthly to the program manager. Any cell that would fall below 10 is combined with another or reported as “fewer than 10”. (S1)
| Field | Entry |
|---|---|
| Month and year | |
| Peer team lead (role); clinical adviser (role) | |
| Active peer supporters at month end (count); on self-care stand-down (count) | |
| Members in scope (count): career / volunteer / dispatch / other |
| Contact type | Career | Volunteer | Dispatch | Other or family | Total |
|---|---|---|---|---|---|
| Post-incident contact (after an activation) | |||||
| Self-referral | |||||
| Officer referral | |||||
| Follow-up contact (2 to 4 weeks) | |||||
| Family contact | |||||
| Total contacts | |||||
| Contacts per 100 members (year to date) |
| Activation number (sequential, no incident number in this log) | Incident type (category only) | Members contacted (count) | Dispatchers contacted (count) | Hours from incident to first peer contact | Group session offered (Y/N); held (Y/N); attended (count or fewer than 10) | Individual referrals made (count) | Follow-up at 2 to 4 weeks done (Y/N) |
|---|---|---|---|---|---|---|---|
| Field | Entry |
|---|---|
| Referrals by destination type (EFAP / vetted clinician / internet CBT / family physician / crisis line / other): counts | |
| Median business days to first clinician appointment this month (sampled) | |
| Supervision sessions held (group / individual counts); peer supporter debriefs after activations (count) | |
| Resource gaps or system issues observed (no names; for example, no coverage on a shift, wait times, a station without postings) | |
| Concerns raised about the peer program (count); answered within 10 working days (count) | |
| Prepared by peer team lead (role), date; sent to program manager (date) |
| Field | Type | Required | Who completes |
|---|---|---|---|
| Month, team size, scope (Part A) | Counts | Monthly | Peer team lead |
| Contacts by type and segment (Part B) | Counts | Monthly | Peer team lead from supporters’ tallies |
| Activations (Part C) | Category, counts, hours, Y/N | Per activation | Peer team lead |
| Referrals, supervision, gaps (Part D) | Counts, text without names | Monthly | Peer team lead; clinical adviser for supervision counts |
| Concerns and answers | Counts | Monthly | Peer team lead; program manager |
- Each peer supporter keeps a private tally (date, contact type, segment, referral made) with no names and no content, and reports the counts to the team lead monthly. Supporters’ tallies are destroyed after the monthly count is recorded.
- The team lead keeps this log in a place the department’s HR and records systems cannot reach, under the custodian rules in Policy - Records, Privacy and Health Information.
- Report to the program manager monthly and to the senior leadership team and the JOHSC quarterly in aggregate; combine any cell below 10.
- An activation row never carries the incident number, the station or the date; the program manager can reconcile activation counts to the critical incident procedure’s own activation count without linking people to events.
- Utilization is a success measure. Rising contacts mean members trust the team, not that the department is in trouble.
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/
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