Form Group Encounter Lo Group Encounter Lo Group Encounter Log

Group Encounter Log

Project #

OMB NO. 0930-0270

Expiration Date XX/XX/XXXX

Provider Name

Provider #

Date of Service
(mm/dd/yyyy)

County of Service

1st Employee #

2nd Employee #

ZIP Code of Service

TYPE OF SERVICE (select one before completing this log)
GROUP COUNSELING
(a group meeting where participants did most of the
talking)

PUBLIC EDUCATION
(a presentation or group meeting where YOU did most of the
talking)

CHARACTERISTICS OF ENCOUNTER
LOCATION of SERVICE (select one)
school and child care (all ages through college)

home (temporary or permanent residence, including friend or
family home; group homes, including houses, apartments,
trailers, and other dwellings)

community center (e.g., recreation club)

retail (e.g., restaurant, mall, shopping center, store)

provider site/mental health agency (agency involved
with the Crisis Counseling Assistance and Training
Program [CCP])

medical center (e.g., doctor, dentist, hospital, substance abuse
specialty center)

workplace (workplace of the disaster survivor and/or
first responder)

public place/event (e.g., street, sidewalk, town square, fair,
festival, sports)

disaster recovery center (e.g., Federal Emergency
Management Agency [FEMA], American Red Cross)

other (specify in box)

place of worship (e.g., church, synagogue, mosque)
SESSION NUMBER (select one)
First session of group
expected to meet once
NUMBER OF PARTICIPANTS
Number under age 18
DURATION

First session of group expected to meet more
than once

Second or greater session of ongoing
group

PLEASE ESTIMATE
Number ages 18-64

15-29 minutes

Number age 65 or older

30-44 minutes

45-59 minutes

TOTAL
60 minutes or more

GROUP IDENTITIES (SELECT ONE)
Was the group composed ONLY or MOSTLY of any of the following:
Children or youth (under age 18)? CHECK, if yes.
Adult survivors (adults who were directly affected by the disaster)? CHECK, if yes.
Public safety workers and first responders (e.g., police, fire, emergency medical services, rescue)? CHECK, if yes.
Other recovery workers (e.g., health care, disaster, relief, social services)? CHECK, if yes.
Was the group composed of a mixture of the above or none of the above (i.e., no clear group identity)? CHECK, if yes.

Ethnicity (select all that apply)
Hispanic or Latino

Not Hispanic or Latino

Race of participants in this encounter (select all that apply)
American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

White

Black or African American

If any of the participants has a disability, or other access or functional need, indicate the type (select all that apply)
Physical (mobility, visual, hearing,
medical, etc.)

Intellectual/Cognitive (learning
disability, mental retardation, etc.)

Mental Health/Substance Abuse
(psychiatric, substance dependence, etc.)

FOCUS OF GROUP SESSION (select all that apply)
INFORMATION/EDUCATION ABOUT:
reactions to
disaster

community resources

this crisis counseling program

managing physical and emotional
reactions (e.g., breathing techniques)

doing positive things

TIPS FOR:
reducing negative
thoughts

problem solving

HEALTHY CONNECTIONS:
mutual support/building social network(s)

participating in community action

other (specify in box)
Were flyers, brochures, handouts, or other materials provided to participants?

Reviewer
Name

YES

NO

Signature

Date of
Review

INSTRUCTIONS:
GROUP ENCOUNTER LOG
When to Use This Form:
1. Complete this form immediately after the group encounter is provided. COMPLETE ONLY ONE FORM PER GROUP.
2. Group sessions involve at least two or more unrelated participants (excluding staff).
3. Do not use this form for families. Use the Individual/Family Crisis Counseling Services Encounter Log
PROJECT #—FEMA disaster declaration number, e.g., DR-XXX-State
PROVIDER NAME—The name of the program/agency.
PROVIDER NUMBER—The unique number under which your program/agency is providing services.
1st EMPLOYEE #—YOUR employee number (must be numeric and no more than 6 digits).
2nd EMPLOYEE #—Employee number of your teammate during this encounter (must be numeric and no more than 6 digits).
DATE OF SERVICE—The date of the encounter in the format mm/dd/yyy, e.g., 01/01/2012.
COUNTY OF SERVICE—The county or parish where the group was held.
ZIP CODE OF SERVICE—The ZIP code of the location where you had the encounter.
GROUP CRISIS COUNSELING OR PUBLIC EDUCATION (SELECT ONE)
THE DATA ON THIS LOG CANNOT BE ENTERED OR COUNTED UNLESS YOU INDICATE TYPE OF SERVICE.
Group crisis counseling refers to services that help group members understand their current situation and reactions to the disaster, review or
discuss their options, obtain emotional support or referral services, and/or develop or improve skills to cope with their current situation and
reactions. In group counseling, participants do most of the talking.

Public education refers to services that provide general psycho-education to survivors on disaster services available and key concepts of disaster
behavioral health. Common activities in this category include, but are not limited to, publich speaking at community forums, in-service group
meetings, and local government meetings. In public education the crisis counselor does most of the talking.
LOCATION OF SERVICE—Where did the encounter occur? SELECT ONLY ONE.
SESSION NUMBER—Check the box beside the option that matches how many times the group has met and will meet. SELECT ONLY ONE.
NUMBER OF PARTICIPANTS—Use all four boxes to report the number of participants (not including staff) and estimate their age distribution. For
example, for seven participants including no adolescents, three adults under age 65, and four other adults, write in 0, 3, 4, 7.
DURATION—How lond did your encounter last? SELECT ONLY ONE. If less than 15 minutes, use the Weekly Tally Sheet form.
GROUP IDENTITIES—This refers to the possible identities and/or roles that the group members might share as a whole. “Primarily” means that
the majority of group members shared the listed characteristic. For example, a group focused on children that had a few adults present would
meet the definition of a group composed “only or mostly” of children. Groups do not necessarily have an identity. If so, check the last box.
ETHNICITY—Based on your observations and your conversation, do any of the participants identify as Hispanic/Latino?
RACE—Based on your observations and your conversation with the participants, what race do you think participants would identify as being?
SELECT ALL THAT APPLY. For a family encounter, if more than once race is represented, you should indicate all races that you believe to be
represented. If participants are of more than one race, you should indicate all races that you believe to be represented.
PERSONS WITH DISABILITIES OR OTHER ACCESS OR FUNCTIONAL NEED(S)—Based on your observations and your conversation with the
participants, does anyone have a physical, intellectual, or mental health/substance abuse disability? SELECT ALL THAT APPLY.
•

Physical: includes disorders that impair mobility, seeing, or hearing, as well as medical conditions, such as diabetes, lupus, Parkinson’s,
AIDS, or multiple sclerosis (MS).

•

Intellectual/Cognitive: includes a learning disability, birth defect, neurological disorder, developmental disability, or traumatic brain injury,
e.g., Down syndrome and mental retardation.

•

Mental Health/Substance Abuse: includes psychiatric disorders, such as bipolar disorder, depression, posttraumatic stress disorder
(PTSD), schizophrenia, and substance dependence.

FOCUS OF GROUP SESSION—What is the focus of this session/encounter? SELECT ALL THAT APPLY. If the focus for the group is different
from the categories listed, please select “OTHER,” and fill in the blank with the primary purpose.
MATERIALS PROVIDED—Did you leave any materials with the participants? This refers to materials such as crisis couseling program brochure,
flyers, tip sheets, or other printed materials. SELECT ONLY ONE (yes/no).
REVIEWER—Team lead or direct supervisor to review completed form for accuracy and then sign and date (date of review).
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: