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pdfDEPARTMENT OF HOMELAND SECURITY
Federal Emergency Management Agency
APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(IMMEDIATE SERVICES PROGRAM)
O.M.B. No. 1660-0085
Expires August 31, 2014
PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this data collection is estimated to average 8 hours per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is required to
obtain or retain benefits. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send
comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of
Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472-3100, Paperwork Reduction Project (1660-0085)
NOTE: Do not send your completed form to this 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).
PURPOSES AND USES: This information is being collected for the primary purpose of determining eligibility for the Crisis Counseling Assistance and Training
Program, Immediate 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 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. This application must be submitted within 14 days following the declaration of a major
disaster.
1. Request Date:
2. Declaration #:
3. Declaration Date:
4. Name of State, Indian Tribal Government or Territory requesting services:
5. Primary POC 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 Immediate Services Program (ISP) funding. (Please round to nearest dollar). $
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 the disaster.
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APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(IMMEDIATE SERVICES PROGRAM)
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. Please also list proposed providers 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. 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.
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 (.075%)
Estimated Population
to be Served Within 60
Days
Number of Direct Staff
Number of Non-Direct
FTEs (Crisis
Staff FTEs (Admin,
counselors, Team
Fiscal, Data, etc.)
Leads) (Typically
Typically 15-20%
300:1 Ratio)
TOTALS:
Please describe any special circumstances not captured in the above table that will have an impact on the need for crisis counseling services.
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). Please include your plan to reach these populations.
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APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(IMMEDIATE SERVICES PROGRAM)
9. Provide a brief description of administrative oversight plans, (supervision and monitoring of crisis counselors, team leads, data collection
efforts, monitoring and managing stress, etc.).
10. CCP requires mandatory training during the ISP as described in the CCP guidance. Please describe additional training (if any) that you
plan to provide and the rationale for providing such training.
10a. Does the State, Indian Tribal Government or Territory have experienced CCP trainers?
YES
NO
PART III: Response Activities
11. Please describe any mental health-specific response activities undertaken from the date of incident to the date of application.
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PART IV: Budget
APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(IMMEDIATE SERVICES PROGRAM)
12. Attach Standard Form 424: Request for Federal Assistance (SF-424) and Standard Form 424a: Budget Information: Non-Construction
Programs. The SF-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 crises 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.
PART V: Assurances
14. Please indicate whether the following assurances have been completed and are being submitted with this application:
a. Lobbying:
YES
NO
b. Drug Free Workplace:
YES
NO
c. Disbarment and Suspension and other Responsibility Matters:
YES
NO
15. By signing below, the Governor or Chief Tribal Executive agrees to and/or certifies that:
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, Indian Tribal Government or Territory will maintain close coordination with and provide reports to the Regional
Administrator.
The State, Indian Tribal Government or Territory's emergency plan, prepared under Title II of the Stafford Act, will include disaster
mental health planning.
16. 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 VI: Application Checklist
17. The following documents have been submitted with this application:
a. Completed ISP 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. Assurances forms in Question 14 above:
YES
NO
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| File Type | application/pdf |
| File Title | FEMA Form |
| File Modified | 2014-06-23 |
| File Created | 2014-06-23 |