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

DEPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICE
(REGULAR SERVICES PROGRAM)

O.M.B. No. 1660-0085

Expires November 30, 2022

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 20 hours per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing, reviewing, and submitting the form. You are not required to respond to this collection of information unless a valid OMB control number appears in the upper right corner of this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing this burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC, 20472, Paperwork Reduction Project (1660-0100). NOTE: Do not send your completed form to the above 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); 44 C.F.R. § 206.171.

PURPOSES AND USES: This information is being collected for the primary purpose of determining eligibility for the Crisis Counseling Assistance and Training Program, Regular 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 Regular Services Program (RSP) 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 no later than 60 days following the declaration of a major disaster.

1. Request Date:      

2. Declaration #:      

3. Declaration Date:      

4. State, Indian Tribal Government or Territory requesting services:      

5. Primary Point of Contact (POC) information 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 Regular Services Program (RSP) funding. (Please round to nearest dollar). $     

PART II: Response Activities from Date of Incident

7. Describe State and local crisis counseling activities from the date of the incident to the date of this application. Enter "N/A" if no crisis counseling activities have been conducted to date.

     

If an Immediate Services Program (ISP) was implemented for this disaster, please answer questions #8-10 below. Otherwise, skip to question #11.

8. Please provide a brief summary of the ISP currently in place. Please include information on the population served, any extensions (date and amount), the number of providers, the start and end dates of the program, and summarize any trends. Include any best practices as well as any challenges and describe how those challenges were addressed or will be addressed in the RSP.

     

9. If applicable, explain why any service providers not included in the ISP were added to this RSP application. Additionally, explain why any service providers included in the ISP are excluded from the proposed RSP.

     

10. Describe how the RSP will build on the work done in the ISP. Describe how contacts and resources identified during the ISP will be leveraged during the RSP.

     

11 Please provide a brief summary that provides key information on the scope and magnitude of the disaster, how the Grantee and providers propose to provide services during the RSP, and the nature and location of the proposed services. Please include a description of the length of time services will be required and describe how long-term cases will be handled. Please describe the nature of psychological and social problems observed and the types of mental health problems encountered by disaster survivors.

     

PART III: Geographic Areas and Needs Assessment

12. 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 data} sources used. 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. 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 during the RSP	Number of Direct Staff FTE's (Crisis Counselors, Team Leads) (Typically a 300:1 ratio)	Number of Direct Support Staff FTE's (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 RSP. 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 RSP is accessible.

     

PART IV: Resources and Capabilities

13. Describe the current mental health resources and explain why they cannot meet the disaster-related mental health needs caused or aggravated by this disaster.

     

14. Has the Grantee received funds for mental health disaster response from any other source (i.e. Department of Education, Foundations, etc) ? If so, how much and how are these funds used?

     

PART V: Program Administration

15. Will the State, Indian Tribal Government or Territory be providing any direct crisis counseling services? YES NO

16. Attach an overall organizational chart for this project.

17. Provide a brief description of administrative oversight plans (supervision and monitoring of crisis counselors, team leads, data collection efforts, managing and monitoring staff stress, etc).

     

18. How will the Grantee monitor the organization and deployment of crisis counseling teams? If more than one provider agency will be delivering services, please describe the plan to coordinate services. If more than one provider will cover a service area, please include a map that shows how the responsibility for that service area will be divided.

     

19. Describe the Grantee's plan for quality control methods to ensure appropriate services reach survivors.

     

20. With what organizations and community stakeholders will you partner? Select all that apply:

Community Mental Health and Substance Abuse Centers

Schools

Faith-Based Organizations

First Responders

Community-Based Cultural Organizations

Law Enforcement

Local Elected Officials

Long-Term Recovery Groups

Other      

21. Briefly describe how you will engage with the partners identified above.

     

22. What primary CCP services will you provide? Please select all that apply.

Individual crisis counseling

Group crisis counseling

Brief educational or supportive contact

Public education

Assessment, referral, and resource linkage

Community networking and support

23. What secondary CCP services will you provide? Please select all that apply.

Development and distribution of educational materials

Media and public service announcements

24. State Staffing Plan. Please provide information on the staffing at the Grantee level. Include leadership positions and direct staff if the State, Territory or Tribe is providing any direct services. Do not include provider-level staff.

Type of Staff	Grant Funded # of Staff Members	Grant Funded # of FTE's (based on 40 hours per week)	Projected In-Kind # of Staff Members	Projected In-Kind # of FTE's (based on 40 hours per week)
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
     	     	     	     	     
Totals:	0.00	0.00	0.00	0.00

25. Describe the Grantee's plan to ensure clear program identity (educational materials, wellness messaging, logos, etc.) and market the program (including website, hotline, social media, public service announcements, etc.)

     

26. Briefly describe the facilities to be utilized and your plan for securing office space for this project.

     

27. The CCP requires mandatory training during the RSP as described in the CCP guidance. Please describe the proposed training program for project staff, indicating the number of workers needing such training. Also include additional training (if any) that you plan to provide and the rationale for such training.

     

28. Does the State, Territory or Tribe have any experienced trainers who can provide training on the CCP model?

YES NO

PART VI: Budget

29. Attach a Standard Form 424: Request for Federal Assistance (SF-424) and Standard Form 424a: Budget Information - Non-Construction Programs (SF-424a). These forms should include all projected operating costs.

30. Attach a budget narrative explaining each line item on the SF-424a.

PART VII: Assurances

31. Please indicate whether the following assurances have been completed and submitted with this application:

1. Budget Narrative: 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 YES NO

6. Project/Performance Site Location Form YES NO

32. The Governor or Chief Tribal Executive agrees to and /or certifies that:

The requirements are beyond the State, local, Territory, or Indian Tribal government's capabilities.

The program, if approved, will be implemented according to the plan contained in the application approved by the Assistant Administrator for the Recovery Directorate.

The State, Indian Tribal Government or Territory will maintain close coordination with and provide reports to the Regional Administrator, the Assistant Administrator for the Recovery Directorate and the Secretary.

The State, Indian Tribal Government or Territory's emergency plan, prepared under Title II of the Stafford Act, will include disaster mental health planning.

33. 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 VIII: Application Checklist

34. The following documents are being submitted with this grant application:

1. Completed RSP 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. Organizational Chart YES NO

7. Assurances forms in Question 31 above YES NO

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