COPLINE

Stephanie Samuels, Creator and Founder

501 Iron Bridge Road #6

Freehold, NJ  07728

(732) 577-8300x8

1-(800) COPLINE

1-(800) 267-5463

Fax: (732) 577-9960

E-mail: Copline@optonline.net

 

 

 

 CONFIDENTIAL VOLUNTEER QUESTIONAIRE

 

 

 

This is a questionnaire to help the Copline facilitators in getting to know you better and to assist with our training of hotline volunteers.  This questionnaire will help us access your readiness to be a volunteer.  The more information we have the more realistic and involved listeners will be.  There will be a lot of role-playing in the training and knowing what people’s strengths and weaknesses are will greatly contribute to the success of the training for both listeners and facilitators.  Although the information is personal, it helps one understand the vulnerability that the caller goes through calling the line as well as how vulnerable one is answering it. The more diversified your background is, the more you can bring to the table of a hotline.  We expect that your experiences as a police officer will result in many ‘Yes’ responses in the questionnaire.  It should be noted that this is not a negative, nor will it preclude you from becoming a listener.   Please use a separate piece of paper to answer the questions.  Being comfortable with ourselves is one of the most important tools we have as listeners.  These questionnaires will be reviewed by the hotline trainers only.  They will be destroyed after the training program is completed.  Welcome to Copline.

 

On the peer support form that we will be asking the peer listeners to be filling out please include the following information:

 

Name, Address, Phone number and E-mail address:

 

Last Department:

 

 

  1. What types of calls do you expect to get on the hotline?

 

Why?

 

  1. What type of call do you feel would be the most comfortable to handle?

 

Why?

 

  1. What type of call would be least comfortable for you to handle?

 

Why?

 

  1. What if any are your concerns about being a volunteer?

 

  1. What if any are your concerns with the Copline itself?

 

  1. Why do you want to be a volunteer on the hotline?

 

  1. What do you expect from the support staff on the hotline?

 

  1. What critical incident sticks out in your mind that you experienced in your career?

 

    1. How did you and or your department handle them?
    2. Do you still dream about it?
    3. Have you been diagnosed with PTSD or Depression?

 

The following questions center around issues related to volunteering on the hotline and prior experiences they’ve had with various resources the hotline might use.

 

  1. Have you or any family members been in therapy?

 

  1. Was it a positive or negative experience and why?

 

  1. Have you or any family member been on or currently on an antidepressant or anti anxiety medication?

 

  1. How many years were in law enforcement?

 

  1. Did you receive an early retirement?  Please explain the circumstances and if it was determined to be an accidental disability?

 

  1. What department(s) did you work for and for how long at each location?

 

  1. What rank did you retire out as?

 

16. During an officers career it is common to be exposed to many psychosocial stressors, especially      being brought up on departmental, civil and or criminal charges.

 

Were you or someone close to you ever brought up on any of these types of charges and found guilty of them.

 

    1. Who was the person and how were you connected to them i.e., self, spouse, child, partner, etc?  
    2. Please tell us what they were and what the outcome was.
    3. Please tell us the effects these incidents had on you both personally and professionally.
    4. How did you handle the stress?

 

  1. Were you or someone close to you ever brought up on any of these types of charges and cleared of them?

 

    1. Who was the person and how were you connected to them i.e., self, spouse, child, partner, etc
    2. Please tell us what they were and what the outcome was.
    3. Please tell us the effects these incidents had on you both personally and professionally.
    4. How did you handle the stress?

 

  1. Has anyone ever told you that you had a drinking problem?  If yes please answer the following questions
    1. Did you agree?
    2. Who was the person(s) that told you?
    3. How did you feel about the person that confronted you?
    4. Did you get help?
    5. What type of help, i.e., AA, inpatient, private counseling, EAP, etc…
    6. Do you still drink?

 

  1. Have you thought about killing yourself?  If yes please answer the following questions
    1. What were the circumstances?
    2. What made you decide to live?

 

20.  Has anyone close to you thought of killing himself or herself?  If yes please answer the following                     questions.

a.        Whom?

b.       What were the circumstances?

c.        How were they going to do it?

 

       21.  Have you or anyone close to you attempted suicide?

    1. Whom?
    2. What were the circumstances?
    3. How were you/they going to do it?

 

  1. Has anyone close to you completed suicide?
    1. Whom?
    2. What were the circumstances?
    3. How did they do it?
    4. How was it handled?

 

  1. Have you had any military experience?
    1. What Branch?
    2. Were you in combat?
    3. Which combat?

 

  1. Please tell us what you do to relieve stress in your life today.

 

  1. Are there any therapists that you are aware of that work with the law enforcement community that you trust to be on a referral list?  Please include their name, address, and phone number so we can contact them for train the trainer courses.

 

  1. Are there any questions that we have not asked that you would like to add to this form?

 

  1. Is there anything you would like to tell us about yourself that you feel would benefit us in getting to know you better?

 

 

Thank you for your time,

 

 

Respectfully,

 

 

Stephanie Samuels

Copline Creator and Founder

 

Please mail, fax or e-mail your questionnaires and answers back to the above address, Attention: Stephanie Samuels.

 

 

*All answers are confidential and privileged information owned by the volunteer.  The questionnaire will only be viewed by Stephanie Samuels, M.A., MSW, LCSW for the purpose of assessing knowledge and tailoring volunteer training on Copline.  The information obtained on this form is for your protection and the protection of callers.  No information will be released without your written consent. *