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 or Parish of Service
2nd Employee #

1st 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 home of
friend or family, group homes, shelters, apartments, trailers,
houses, and other dwellings)

community center (e.g., recreation club)
provider site/mental health agency (agency involved
with the Crisis Counseling Assistance and Training
Program [CCP])

retail (e.g., restaurant, mall, shopping center, store)
medical center (e.g., doctor, dentist, hospital, substance use
disorder specialty center)
public place/event (e.g., street, sidewalk, town square, fair,
festival, sports)

workplace (workplace of the disaster survivor and/or
first responder)
disaster recovery center (e.g., Federal Emergency
Management Agency [FEMA], American Red Cross)

virtual (e.g., text line, online chat service, Zoom)

place of worship (e.g., church, synagogue, mosque)

other (specify in box)

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 later 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
Was the group composed ONLY or MOSTLY of any of the following: (select one)
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.

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

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

Hispanic or Latino

Did any of the participants move from another country to the United States in the past 5
years? (select one)

Yes

No

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, developmental delay, etc.)

Mental health/substance use (psychiatric,
substance use disorder, etc.)

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

community resources

this crisis counseling program (CCP)

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? (select one)

YES

NO

INSTRUCTIONS:
GROUP ENCOUNTER LOG
When To Use This Form:
1.
2.
3.

Complete this form immediately after the group encounter is provided. COMPLETE ONLY ONE FORM PER GROUP.
Group sessions involve at least two or more unrelated participants (excluding staff).
Do not use this form for families. Use the Individual/Family Crisis Counseling Services Encounter Log.

PROJECT #—FEMA disaster declaration number, e.g., State-XXXX.
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 issued by ODCES (must be numeric and no more than 6 digits).
2nd EMPLOYEE #—Employee number issued by ODCES for 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/yyyy, e.g., 01/01/2021.
COUNTY OR PARISH 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 ONLY 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 they can use 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, public 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 long 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.
RACE/ETHNICITY—Based on your observations and your conversation with the participants, what race/ethnicity do you think participants
would identify as being? SELECT ALL THAT APPLY. If participants are of more than one race/ethnicity, indicate all races/ethnicities that you
believe to be represented.
MOVED TO THE UNITED STATES IN THE PAST 5 YEARS— Indicate if any participant moved to the United States in the past 5 years from
any country and for any reason. SELECT ONLY ONE (yes/no).
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 use-related 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,acquired immunodeficiency syndrome (AIDS), or multiple sclerosis (MS).
Intellectual/cognitive: includes a learning disability, birth defect, neurological disorder, developmental disability (e.g., Down syndrome),
or traumatic brain injury.
Mental health/substance use: includes psychiatric disorders, such as bipolar disorder, major depression, posttraumatic stress
disorder(PTSD), schizophrenia, and substance use disorders.

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 counseling program (CCP)
brochure, flyers, tip sheets, or other materials. SELECT ONLY ONE (yes/no).
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 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 5 minutes per encounter, 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 Lane, Room 15E57A, Rockville, MD
20857.