FEMA Form FF-104-F CCP/ISP Crisis Counseling Assistance and Training Progra

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(IMMEDIATE SERVICES PROGRAM)

O.M.B. No. 1660-0085

Expires November 30, 2022

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 Point of Contact (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.

     

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 the proposed providers and the number of direct and direct support 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. For "Percentage Impact Factor" use .0075%. Multiply the "Total Census Population" by .0075% to arrive at the estimated population to be served during the ISP. Please also list the number of direct and direct support staff anticipated.

Service Provider Name (if known) and Requested Declared Service Areas	Total Census Population in Requested Declared Service Areas	Percentage Impact Factor (.0075%)	Estimated Population to be Served Within 60 Days	Number of Direct Staff FTEs (Crisis counselors, Team Leads) (Typically 300:1 Ratio)	Number of Direct Support Staff FTEs (Admin, Fiscal, Data, etc.) Typically 15-20%
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
     	     	     	     	     	     
TOTALS:	0.00		0.00	0.00	0.00

Describe any circumstances not captured in the table above that will have an impact on the need for and equitable delivery of crisis counseling services during the ISP. Include any high-risk groups or populations of concern (e.g., children; adolescents; older adults; individuals with disabilities; cultural needs; access and functional needs; lower income populations; first responders; etc.). Please include your plan to ensure the ISP is accessible.

     

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.

     

PART IV: Budget

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 crisis 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:

1. Lobbying Certification Form (if not already on file with FEMA): YES NO

2. SF-424, Application for Federal Assistance: YES NO

3. SF-424A, Budget for Non-Construction Projects: YES NO

4. SF-424B, Assurance for Non-Construction Projects: YES NO

5. SF-LLL Disclosure of Lobbying Activities (if applicable): 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:

1. Completed ISP Application YES NO

2. Request for Federal Assistance (SF-424) YES NO

3. Budget Information - Non-Construction Programs (SF-424a) YES NO

4. Assurances for Non-Construction Programs (SF-424b) YES NO

5. Budget Narrative YES NO

6. Assurances forms in Question 14 above: YES NO

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