Forms Revision Chart for FEMA Form 003-0-1

FEMA Form 003-0-1, Immediate Services Program Application

LOCATION	CURRENT TEXT	REVISED TEXT
p. 1, #1a	Question wording here …………………………………………………………………………………………………………………………………………………………………………………… a) answer choice b) answer choice c) answer choice	(Example: This question is now removed.)
p.1	Title page includes Title, Paperwork Burden Disclosure, OMB #, FEMA Form # and Privacy Act Statement	OMB #, Paperwork Burden Disclosure, Privacy Act Statement, and FEMA Form # and the following: PART I: General Application Information: (1.) Request Date: (2.) Declaration #: (3.) Declaration Date: Completion of this form including applicable attachments satisfies legal requirements for application for the Immediate Services Program (ISP) 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. (4.) Name of State, Territory or Tribe requesting services: (5) Primary POC for the administration of this program: Name, Organization, Mailing Address, Email Address and Phone Number(s) (6). The Grantee requests $ _for Immediate Services Program (ISP) funding. (Please round to the nearest dollar)
p. 2	Attention Grant Preparer Please refer to the Immediate Services Program (ISP) Supplemental Instructions for detailed information for completing this application. You can find the ISP Supplemental Instructions in the Crisis Counseling Assistance and Training Program (CCP) Application Toolkit or by calling the Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center (SAMHSA DTAC) at 1-800-308-3515. Please complete all footer notes with the corresponding disaster information.	Part II – Plan of Service/Needs Assessment – (7) Please describe current State and local mental health services and explain why they cannot meet the disaster-related mental health needs caused or aggravated by this disaster. (8) 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 any data sources used and the methodology used to determine the estimated population to be served. (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. Multiply the total census by the “percentage impact factor of .075” by the “total census population” to arrive at an estimated population to be served during the ISP. High impact events may require more than .075% while lower impact events may require less. (TABLE)
p.3	Request for State Mental Health Authority Signature and the Governor’s Authorized Representative’s Signature	(9) Provide a brief description of oversight plans, including administrative (supervision and monitoring of crisis counselors, team leads, data collection efforts) and fiscal (monitoring and managing staff stress, etc). (10) CCP requires mandatory training during the ISP. Please describe additional training (if any) that you plan to provide. Does the State, Territory or Tribe have experienced in-state trainers who can provide training on the CCP model? Yes or No
Page 4	Contact Information – for the Preparer, Point of Contact for the grant, and an Alternate Point of Contact	Part III: Response Activities – (11) Please describe any mental health-specific response activities undertaken from the date of incident to the date of application. Part IV: Budget - (12) Attach Standard Form 424 Request for Federal Assistance (SF–424) and Standard Form 424a Budget Information: Non-Construction Programs. The 424 should include all projected operating costs as well as pre-award costs, if any. Pre-award Costs: Grantees may request reimbursement for costs associated with crisis counseling services provided from the date of the incident to the date of the ISP application. Reimbursement is limited to crisis counseling services allowable under the CCP and not for any other type of behavioral health response and must be approved in writing. (13) Attach a Budget Narrative explaining each line item on the SF 424a. Identify pre-award costs requested, if any. (14) Additional Comments, if any Part V – Assurances (15) Please indicate whether the following assurances have been completed and submitted with this application: Lobbying Yes No Drug-Free Workplace Yes No Debarment and Suspension Yes No
Page 4 continued	Needs Assessment Guidance Use the Needs Assessment Formula Table to develop an estimate of the number of people who would benefit from services. Please refer to the following guidelines when completing the table: Consult with your FEMA Program Specialist and Center for Mental Health Services (CMHS) Project Officer prior to completing the Needs Assessment Table. Preliminary Damage Assessment (PDA): When available, you must use the PDA data in the table. FEMA Individual Assistance (IA) Registration Numbers: IA data should be used only when PDA data are unavailable and requires prior approval from FEMA and CMHS. Use the “other” category to supply the IA data. Additional data should not be included when using IA numbers. Capture additional supporting information in the narrative. The Average Number of People per Household (ANH) multiplier is not to be used with IA numbers. The Traumatic Impact Risk Ratio to be used in the table should be 100%. Estimated Number to be Served Primary Services—To determine the estimated number of people to be served through PRIMARY services, you may use a multiplier “between 20% and 80%.” This number should be based on the nature and scope of the disaster and the capacity to address the need. Secondary Services—To determine the estimated number of people to be served through SECONDARY services, you may use a multiplier of “up to 100%.” Complete a CMHS Needs Assessment Formula Table for each designated area to be covered by the grant. Use the following steps to complete the table: Identify the number of people for each loss category from collected needs assessment information. Identify any disaster- or region-specific “other”1 loss categories, and establish a traumatic impact risk ratio for any other loss categories. Note that other loss categories are not multiplied by the household size multiplier. Determine the total number of people who would benefit from services for each loss category by multiplying across each row as follows: (Number of People) X (Household Size Multiplier) X (Traumatic Impact Risk Ratio) = (Total Number of People Who Would Benefit from Services). Add all of the results in the column of Total Number of People Who Would Benefit from Services to determine a sum for the number of people who would benefit from crisis counseling services.	(16) The Governor or Tribal Chief Executive agrees to and/or certifies that the following are true: The requirements are beyond the State, Territory, or Tribal government’s capabilities. The Program, if approved, will be implemented according to the plan contained in the application approved by the Regional Administrator. The State, Territory or Tribe will maintain close coordination with and provide reports to the Regional Administrator. (17) By signing below the GAR or the Tribal chief Executive affirms that the foregoing questions have been answered correctly and truthfully to the best of their knowledge. PART VI - Application Checklist (18) The following documents have been submitted with this application: Completed ISP Application Yes No Request for Federal Assistance (SF 424) Yes No Budget Information – Non Construction Programs (SF 424A) Yes No Assurances for Non-Construction Programs (SF-424b) Yes No Budget Narrative Yes No Assurances forms in Question 15 above Yes No
p.6 - 25	Part II. Response Activities from Date of Incident Part III. State and Local Resources and Capabilities Part IV. Plan of Services Part V. Budget	These sections are removed