Form FEMA Form 003-0-2 FEMA Form 003-0-2 Application for Crisis Counseling Program Services (Regu

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency
APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

O.M.B. No. 1660-0085
Expires August 31, 2014

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average 20 hours per response. The burden estimate includes the time for reviewing instructions, searching
existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this
collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden
estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency
Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0100). NOTE: Do not send your completed form to the
above address.
Privacy Act Statement
GENERAL: The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a (b) of the Privacy Act of 1974, as amended. This
includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 004 Grant Management Information Files System of
Records, 74 Fed. Reg. 39705 (August 7, 2009) and upon written request, by consent, by agreement, or as required by law.
AUTHORITY: Section 416 of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended (42 U.S.C. § 5183); 44 C.F.R. § 206.171.
PURPOSES AND USES: This information is being collected for the primary purpose of determining eligibility for the Crisis Counseling Assistance and Training
Program, Regular Services Program funding following a Presidentially-declared disaster.
EFFECTS OF NONDISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or
prevent FEMA from providing the requested funding.

PART I: General Application Information
Completion of this form including applicable attachments satisfies legal requirements for application for the Regular Services Program (RSP)
under 42 U.S.C. § 5183 as implemented at 44 C.F.R. § 206.171. Failure to use this application may result in a failure to meet these
requirements and/or a delay in processing the request. This application must be submitted no later than 60 days following the declaration of a
major disaster.
1. Request Date:

2. Declaration #:

3. Declaration Date:

4. State, Indian Tribal Government or Territory requesting services:
5. Primary Point of Contact (POC) information for the administration of this program.
5a. POC Name:
5b. POC Organization:
5c. POC Mailing Address:
5d. POC E-Mail Address:
5e. POC Phone Number
6. Amount requested for Regular Services Program (RSP) funding (please round to nearest dollar). $
PART II: Response Activities from Date of Incident
7. Describe State and local crisis counseling activities from the date of the incident to the date of this application. Enter "N/A" if no crisis
counseling activities have been conducted to date.

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 1 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)
If an Immediate Services Program (ISP) was implemented for this disaster, please answer questions #8-10 below. Otherwise, skip to question
#11.
8. Please provide a brief summary of the ISP currently in place. Please include information on the population served, any extensions (date
and amount), the number of providers, the start and end dates of the program, and summarize any trends. Include any best practices as well
as any challenges and describe how those challenges were addressed or will be addressed in the RSP.

9. If applicable, explain why any service providers not included in the ISP were added to this RSP application. Additionally, explain why any
service providers included in the ISP are excluded from the proposed RSP.

10. Describe how the RSP will build on the work done in the ISP. Describe how contacts and resources identified during the ISP will be
leveraged during the RSP.

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 2 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

11. Please provide a brief summary that provides key information on the scope and magnitude of the disaster, how the Grantee and providers
propose to provide services during the RSP, and the nature and location of the proposed services. Please include a description of the length of
time services will be required and describe how long-term cases will be handled. Please describe the nature of psychological and social
problems observed and the types of mental health problems encountered by disaster survivors.

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 3 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

PART III: Geographic Areas and Needs Assessment
12. Estimated Population to be served:

OPTION A: Grantees may opt to use their own method for determining the estimated population to be served. Please cite data
sources used. Please also list the proposed providers and the number of direct and non-direct staff anticipated.

OPTION B: Use the following table to estimate the impacted population for each requested service area (county, parish, tribal
land, etc.). Populate the table using census data for the total population for each designated service area. For "Percentage Impact
Factor" use .075%. Multiply the "Total Census Population" by .075% to arrive at the estimated population to be served. Please also list
the number of direct and non-direct staff anticipated.
Service Provider
Name (if known) and
Requested Declared
Service Areas

Total Census
Population in
Requested Declared
Service Areas

Percentage Impact
Factor (.75%)

Estimated Population
to be Served during
the RSP

Number of Direct Staff
Number of Non-Direct
FTE's (Crisis
Staff FTE's (Admin.,
Counselors, Team
Fiscal, Data etc.)
Leads) (Typically a
Typically 15-20%
300:1 ratio)

TOTALS:
FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 4 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

Describe any special circumstances not captured in the table above that will have an impact on the need for crisis counseling services during
the RSP. Include any high-risk groups or populations of concern (e.g. children; adolescents; older adults; ethnic and cultural groups; access and
functional needs; lower income populations, first responders, etc). Please include your plan to reach these populations.

PART IV: Resources and Capabilities
13. Describe the current mental health resources and explain why they cannot meet the disaster-related mental health needs caused or
aggravated by this disaster.

14. Has the Grantee received funds for mental health disaster response from any other source (i.e. Department of Education, Foundations,
etc) ? If so, how much and how are these funds used?

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 5 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

PART V: Program Administration

15. Will the State, Indian Tribal Government or Territory be providing any direct crisis counseling services?
Yes

No

16. Attach an overall organizational chart for this project
17. Provide a brief description of administrative oversight plans (supervision and monitoring of crisis counselors, team leads, data collection
efforts, managing and monitoring staff stress, etc).

18. How will the Grantee monitor the organization and deployment of crisis counseling teams? If more than one provider agency will be
delivering services, please describe the plan to coordinate services. If more than one provider will cover a service area, please include a map
that shows how the responsibility for that service area will be divided.

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 6 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)

19. Describe the Grantee's plan for quality control methods to ensure appropriate services reach survivors.

20. With what organizations and community stakeholders will you partner? Select all that apply:
Community Mental Health and Substance Abuse Centers
Schools
Faith-Based Organizations
First Responders
Community-Based Cultural Organizations
Law Enforcement
Local Elected Officials
Long-Term Recovery Groups
Other:
21. Briefly describe how you will engage with the partners identified above.

22. What primary CCP services will you provide? Please select all that apply.
Individual crisis counseling
Group crisis counseling
Brief educational or supportive contact
Public education
Assessment, referral, and resource linkage
Community networking and support

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 7 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)
23. What secondary CCP services will you provide? Please select all that apply.
Development and distribution of educational materials
Media and public service announcements
24. State Staffing Plan. Please provide information on the staffing at the Grantee level. Include leadership positions and direct staff if the
State, Territory or Tribe is providing any direct services. Do not include provider-level staff.

Grant Funded

Type of Staff

# of Staff Members

# of FTE's (based on 40
hours per week)

Projected In-Kind

# of Staff Members

# of FTE's (based on 40
hours per week)

Totals:

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 8 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)
25. Describe the Grantee's plan to ensure clear program identity (educational materials, wellness messaging, logos, etc.) and market the
program (including website, hotline, social media, public service announcements, etc.)

26. Briefly describe the facilities to be utilized and your plan for securing office space for this project.

27. The CCP requires mandatory training during the RSP as described in the CCP guidance. Please describe the proposed training program
for project staff, indicating the number of workers needing such training. Also include additional training (if any) that you plan to provide and
the rationale for such training.

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 9 of 10

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES
(REGULAR SERVICES PROGRAM)
28. Does the State, Territory or Tribe have any experienced trainers who can provide training on the CCP model?

YES

NO

PART VI: Budget
29. Attach a Standard Form 424: Request for Federal Assistance (SF-424) and Standard Form 424a: Budget Information - Non-Construction
Programs (SF-424a). These forms should include all projected operating costs.
30. Attach a budget narrative explaining each line item on the SF-424a.
PART VII: Assurances
31. Please indicate whether the following assurances have been completed and submitted with this application:
a. Lobbying

YES

NO

b. Drug-Free Workplace

YES

NO

c. Disbarment, Suspension and Other Responsibility Matters

YES

d. HHS Project Checklist

YES

NO

e. HHS Project Site Location Form

YES

NO

NO

32. The Governor or Chief Tribal Executive agrees to and /or certifies that:
The requirements are beyond the State, local, Territory, or Indian Tribal government's capabilities.
The program, if approved, will be implemented according to the plan contained in the application approved by the Assistant
Administrator for the Recovery Directorate.
The State, Indian Tribal Government or Territory will maintain close coordination with and provide reports to the Regional
Administrator, the Assistant Administrator for the Recovery Directorate and the Secretary.
The State, Indian Tribal Government or Territory's emergency plan, prepared under Title II of the Stafford Act, will include disaster
mental health planning.
33. By signing below, the Governor's Authorized Representative (GAR) or the Chief Tribal Executive affirms that the foregoing questions have
been answered correctly and truthfully to the best of their knowledge.

Signature

Date

PART VIII: Application Checklist
34. The following documents are being submitted with this grant application:
a. Completed RSP Application

YES

NO

b. Request for Federal Assistance (SF-424)

YES

NO

c. Budget Information - Non-Construction Programs (SF-424a)

YES

NO

d. Assurances for Non-Construction Programs (SF-424b)

YES

NO

e. Budget Narrative

YES

NO

f. Organizational Chart

YES

NO

g. Assurance forms from question 31 above

YES

NO

FEMA FORM 003-0-2

PREVIOUS EDITION OBSOLETE

Page 10 of 10