Weekly Tally Sheet Weekly Talkly Sheet

OMB NO. 0930-0270
Expiration Date XX/XX/XXXX

Project #

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

TYPE OF CONTACT

NUMBER OF CONTACTS OR NUMBERS DISTRIBUTED
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

Do not include materials that are captured on individual/family or group encounter data collection forms.

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 NUMBER DISTRIBUTED—For each day of the week, fill in the total number of contacts for each
of the following types:
IN PERSON BRIEF EDUCATION 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 crisis counselor 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!
Paperwork Reduction Act Statement This information is being collected to assist the Substance Abuse and Mental Health Services Administration (SAMHSA)
with program monitoring of FEMA’s Crisis Counseling Assistance and Training Program. Crisis counselors are required to complete this form following the
delivery of crisis counseling services to disaster survivors (44 CFR 206.171 [F][3]). Information collected through this form will be used at an aggregate level to
determine the reach, consistency, and quality of the Crisis Counseling Assistance and Training Program. Under the Privacy Act of 1974, any personally
identifying information obtained will be kept private to the extent of the law. 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 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 week, 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, 5600 Fishers Ln, Room
15E57B, Rockville, MD 20857.