Form Weekly_Tally_Sheet

Project # OMB NO. 0930-0270

Expiration Date xx/xx/xxxx

Weekly Tally Sheet

Brief Educational and Supportive Services Not Elsewhere Included

Provider Name

County or Parish Provider Number

Week Beginning mm/dd/yyyy Employee ID

	NUMBER OF CONTACTS OR NUMBERS DISTRIBUTED
TYPE OF CONTACT	SUN.	MON.	TUES.	WED.	THURS.	FRI.	SAT.	TOTAL
In-person brief educational or supportive contact
Telephone contact by crisis counselor
Hotline/helpline/lifeline contact
Email contact
Community networking and coalition building
MATERIALS DISTRIBUTED
Material handed to people
Material mailed to people’s homes and/or left at a person’s unattended home
Material left in public places
Mass media
Social networking messages

Note: If the number is zero, the field may be left blank.

Reviewer Name Signature Date of Review

INSTRUCTIONS:

WEEKLY TALLY SHEET

BRIEF EDUCATIONAL AND SUPPORTIVE SERVICES (NOT ELSEWHERE INCLUDED)

When to Use This Form:

This sheet is intended to capture all of the contacts you have had for a particular week that have not been captured on any other form. In other words, if you have completed an Individual/Family Crisis Counseling Services Encounter Log for someone, or if you have counted someone as a participant on the Group Encounter Log, you will not count that person or the materials handed out during those encounters here.

NUMBER OF CONTACTS OR NUMBERS DISTRIBUTED­—For each day of the week, fill in the total number of contacts for each of the following types:

IN PERSON BRIEF EDUCATIONAL OR SUPPORTIVE CONTACT—The number of brief contacts with individuals, or groups of individuals, that did not result in in-depth discussion or interaction of an educational or crisis counseling nature. Record this contact on the Weekly Tally Sheet when it is less than 15 minutes. (If your contact is more than 15 minutes, please fill out the Individual/Family Crisis Counseling Services Encounter Log.) If you also distributed materials during this interaction, you will record that under the “MATERIALS DISTRIBUTED” section of this form.

TELEPHONE CONTACT BY CRISIS COUNSELOR—The number of brief telephone contacts with individuals that did not result in in-depth discussion or interaction of an educational or crisis counseling nature. Record this contact on the Weekly Tally Sheet when it is less than 15 minutes. (If your contact is more than 15 minutes, please fill out the Individual/Family Crisis Counseling Services Encounter Log.)

HOTLINE/HELPLINE/LIFELINE CONTACT—The number of calls that come into the hotline/helpline/lifeline designated for this Crisis Counseling Assistance and Training Program (CCP). Record this contact on the Weekly Tally Sheet when it is less than 15 minutes. (If your contact is more than 15 minutes, please fill out the Individual/Family Crisis Counseling Services Encounter Log.)

EMAIL CONTACT—The number of brief email contacts with individuals that did not result in in-depth discussion or interaction of an educational or crisis counseling nature.

COMMUNITY NETWORKING AND COALITION BUILDING—How many people did you come into contact with for the purpose of networking within the community or building local coalitions? (Did you build relationships with community resource organizations, faith-based groups, and local agencies? Did you attend a community event to provide a compassionate presence and to be available to provide crisis counseling services, if needed? Did you initiate or attend an unmet-needs committee or long-term recovery meeting, or other disaster relief–oriented gathering?)

MATERIAL HANDED TO PEOPLE—How many packets or materials were distributed by handing them out to people with no or minimal contact? (One packet of information, even if containing multiple pieces, is counted as one.)

MATERIAL MAILED TO PEOPLE’S HOMES AND/OR LEFT AT A PERSON’S UNATTENDED HOME—How many packets or materials were mailed to people’s homes and/or left at people’s homes when they were not there (with no interaction with the people living in the homes)? (If you left a packet of information on a doorstep, count it as one material item left, even if the packet contained multiple pieces.)

MATERIAL LEFT IN PUBLIC PLACES—How many materials were left in public places?

For this crisis counseling program, the following may be captured by the CC or by the administrative program staff:

MASS MEDIA—How many mass media messages did you publish or broadcast? This includes newspaper ads, radio broadcasts, listserv mailings, advertisements, etc. that were created or developed by the program. This does not include surface mailing of materials, which is recorded above under MATERIAL MAILED. In general, the number of people “receiving” messages through mass media will be unknown (e.g., the number of people reading your newspaper ad is unknown), therefore, do not record the reach of the message - only the number of messages published or broadcasted.

SOCIAL NETWORKING MESSAGES—How many messages did you post via social networking mechanisms (e.g., Facebook or Twitter)? Do NOT include the number of replies or posts made by outside parties.

Please submit the completed form to the designated person in your agency who will review and sign the form.

Thank you for taking the time to complete this form accurately and fully!

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid Office of Management and Budget (OMB) control number. The OMB control number for this project is 0930-0270. Public reporting burden for this collection of information is estimated to average 12 minutes per Weekly Tally Sheet, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, MD 20857.