Forms Revision Chart for FEMA Form 003-0-2

FEMA Form 003-0-2, Regular Services Program Application

LOCATION	CURRENT TEXT	REVISED TEXT
p. 1, #1a	Question wording here …………………………………………………………………………………………………………………………………………………………………………………… a) answer choice b) answer choice c) answer choice	(Example: This question is now removed.)
	Old question wording.	New question wording.
p.1	Title page includes Title, Paperwork Burden Disclosure, OMB #, FEMA Form # and Privacy Act Statement	FEMA, Application for Crisis Counseling Program Services Program, OMB #, Paperwork Burden Disclosure, Privacy Act Statement, and FEMA Form # and the following: 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 (4.) State, Territory or Tribe requesting services: (5) Name, Organization, Mailing Address, Email Address and Phone Number(s) for the Primary Point of Contact (POC) for administering this program. (6) Amount requested for Regular Services Program (RSP) funding. (Please round to the 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.
p.2	Attention Grant Preparer Please refer to the Immediate Services Program (ISP) Supplemental Instructions for detailed information for completing this application. You can find the ISP Supplemental Instructions in the Crisis Counseling Assistance and Training Program (CCP) Application Toolkit or by calling the Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center (SAMHSA DTAC) at 1-800-308-3515. Please complete all footer notes with the corresponding disaster information.	If an immediate Services Program (ISP) was implemented for this disaster, please answer questions #8-10 below. Otherwise, skip to question #11. (8) provide a brief summary of the ISP. Please include information on the population served, any extensions (date and amount), the number of providers, the start and end date 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 proposed for exclusion in the RSP. (10) If the Grantee received an ISP grant, 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.
p.3	Request for State Mental Health Authority Signature and the Governor’s Authorized Representative’s Signature	(11) Please provide an brief summary that provides key information on the scope and magnitude of the disaster; how the Grantee and service 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.
p.4	Contact Information – for the Preparer, Point of Contact for the grant, and an Alternate Point of Contact	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 any data sources used. List providers and the number of direct and non-direct staff for each. 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 .075% Multiply the total census population by .075% to arrive at the estimated population to be served. Higher impact events may require more than .075% while lower impact event may require less than .075%. TABLE
p.5	Executive Summary Include an executive summary below that provides key information on the scope and magnitude of the disaster, how the State responded initially, how the State and community service providers propose to provide services during the RSP, and the nature and location of the services. It is recommended that this section be completed last, after all other key information has been determined. The executive summary should not exceed one page in length. Part I. Disaster Description A. Narrative Description Please answer the following questions that describe the disaster and its impact on survivors and communities. What was the timeframe during which the disaster occurred? What was the date of the Presidential disaster declaration? Was the disaster the result of natural causes (e.g., hurricane, tornado, earthquake, wildfire, flood), the result of an accident (e.g., accidental fire), or a deliberate criminal act (e.g., bombing)? How much warning did disaster victims or survivors have? How long did the actual disaster last? Was disaster damage concentrated in small areas or widely dispersed? Provide examples of major damage caused by the disaster and the overall impact on survivors. Describe the social, economic, and demographic characteristics of the affected communities and whether the communities are primarily rural, suburban, or urban. Did disaster response organizations encounter any particular challenges in reaching specific communities? Additional comments, if any: B. Map of the Disaster Area Include or attach a map of the State, highlighting the counties or service areas included in the Presidential disaster declaration.	Describe any special circumstances not captured in the table above that will have an impact on the need for crisis counseling services during the RSP. Include any high-risk groups or populations of concern (e.g. children; adolescents; older adults; ethnic and cultural groups; access and functional needs; lower income populations, first responders, etc). Please include your plan to reach these populations. PART IV - Resources and Capabilities (13) Describe the current State and local mental health resources and explain why current mental health resources 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., Dept of Education, foundations, etc) ? If so, how much and how are these funds used? Additional Comments, if any.
p.6	Needs Assessment Guidance: Use the Needs Assessment Formula Table to develop an estimate of the number of people who would benefit from services. Please refer to the following guidelines when completing the table: Consult with your FEMA Program Specialist and Center for Mental Health Services (CMHS) Project Officer prior to completing the Needs Assessment Table. Preliminary Damage Assessment (PDA): When available, you must use the PDA data in the table. FEMA Individual Assistance (IA) Registration Numbers: IA data should be used only when PDA data are unavailable and requires prior approval from FEMA and CMHS. Use the “other” category to supply the IA data. Additional data should not be included when using IA numbers. Capture additional supporting information in the narrative. The Average Number of People per Household (ANH) multiplier is not to be used with IA numbers. The Traumatic Impact Risk Ratio to be used in the table should be 100%. Estimated Number to be Served Primary Services—To determine the estimated number of people to be served through PRIMARY services, you may use a multiplier “between 20% and 80%.” This number should be based on the nature and scope of the disaster and the capacity to address the need. Secondary Services—To determine the estimated number of people to be served through SECONDARY services, you may use a multiplier of “up to 100%.” Complete a CMHS Needs Assessment Formula Table for each designated area to be covered by the grant. Use the following steps to complete the table: 1.Identify the number of people for each loss category from collected needs assessment information. Identify any disaster- or region-specific “other”1 loss categories, and establish a traumatic impact risk ratio for any other loss categories. Note that other loss categories are not multiplied by the household size multiplier. Determine the total number of people who would benefit from services for each loss category by multiplying across each row as follows: (Number of People) X (Household Size Multiplier) X (Traumatic Impact Risk Ratio) = (Total Number of People Who Would Benefit from Services). Add all of the results in the column of Total Number of People Who Would Benefit from Services to determine a sum for the number of people who would benefit from crisis counseling services.	Part V: Program Administration (15) Will the State, Territory or Tribe be providing any direct crisis counseling services ? YES NO (16) Attach an overall organizational chart for this project. (17) Provide a brief description of oversight plans, including administrative (supervision and monitoring of crisis counselors, team leads, data collection efforts and fiscal, 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 will cover a service area, please include a map that shows how the responsibility for that service will be divided up.
p.7	-TABLE- If appropriate, the State may identify other loss category groups related to the disaster. These categories are not multiplied by a Household Size Multiplier. The State should also identify a Traumatic Impact Risk Ratio for each additional loss category specified. Add rows as necessary. 2Household Size Multiplier means the average number of people per household (ANH). The national average is 2.5, but applicants should consult U.S. Census information for State or county averages. 3The Traumatic Impact Risk Ratio assesses the likelihood of individual and community adverse reactions to this disaster. In previous versions of this application, the term “at-risk multiplier” was used. Identify the sources of data for the number of people identified in each loss category. If FEMA preliminary damage assessment data have not been collected for this disaster or were not used in specifying the number of people for each category, please clearly identify alternate sources of data used (e.g., American Red Cross, State Emergency Management Agency, media reports). Describe any special circumstances not captured in the CMHS Needs Assessment Formula that will affect the need for crisis counseling services. Specify any high-risk groups or populations of special concern identified through the State’s initial needs assessment process (e.g., children, adolescents, older adults, ethnic and cultural groups, lower income populations). If “other” categories were added to the CMHS Needs Assessment Formula Table, please describe the rationale for including these loss categories and how the Traumatic Impact Risk Ratios were determined. Additional comments, if any:	(19) Describe the Grantee’s plan for quality control methods to ensure appropriate services reach survivors (20) With what organizations and community stakeholders with 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? Select all that apply: (individual and group crisis counseling; brief educational or supportive contact; public education; assessment referral and resource linkage; and community networking and support).
p.8	B. Estimated Number of People to Be Served Through Primary and Secondary Services This is an estimate for the following designated service area: Date completed: For each designated service area, complete the table of estimated number of people to be served (below). Use the following steps to complete the table: For each Loss Category, list the Total Number of People Who Would Benefit from Services based on the CMHS Needs Assessment Formula table. Identify a percent multiplier for primary services and a percent multiplier for secondary services. These multipliers indicate the percentage of people the program expects to actually serve out of the total number of people who would benefit from services in the designated area. Note that individuals may receive both primary and secondary services. Primary and secondary percent multipliers may vary according to the loss category. Please see the Needs Assessment Guidance on page 6 of this application for information on identifying Primary and Secondary Percent Multipliers. To determine the estimated number of people to be served through primary services for each loss category, multiply the total number of people for each loss category by the primary percent multiplier: (Total Number of People Who Would Benefit from Services) X (Primary Percent Multiplier) = (Number of People To Be Served Through Primary Services). To determine the estimated number of people to be served through secondary services for each loss category, multiply the total number of people for each loss category by the secondary percent multiplier: (Total Number of People Who Would Benefit from Services) X (Secondary Percent Multiplier) = (Number of People To Be Served Through Secondary Services). Sum the column items of Number of People To Be Served to identify a total for each designated service area. -TABLE- Primary Services: Individual crisis counseling; group crisis counseling; assessment, referral, and resource linkage; community networking; basic supportive/educational contacts; and public education presentation/groups. Secondary Services: Media/public service announcements, distribution of educational materials (including e-mail and Web sites). Provide a rationale for estimating the total number of people to be served through primary and secondary services.	(23) What secondary services will you provide? 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. -TABLE-
p.9	C. Summary of Geographic Areas and Needs Assessment Use the following steps to complete the chart below: Complete a CMHS Needs Assessment Formula Table for each designated service area (see Part II.A.). Complete the Table of Estimated Number of People To Be Served Through Primary and Secondary Services for each designated service area (see Part II.B.). Using the information from each CMHS Needs Assessment Formula Table, fill in the first two columns of the chart below. Using the totals from the Table of Estimated Number of People To Be Served Through Primary and Secondary Services, fill in the last two columns of the following chart. These totals should reflect the sum of the estimated number of people to be served through primary and secondary services in each designated service area. -TABLE- Additional Comments, if any. Part III. Response Activities from Date of Incident A. Description of Response Activities from Date of Incident Describe State and local crisis counseling activities from the date of the incident to the date of this application. Enter “none” if no activities have been conducted to date. B. Immediate Services Program Activities This section should be completed only if the State received an Immediate Services Program (ISP) grant for the disaster. Skip this section if the State did not receive an ISP grant. This section fulfills the requirement for an ISP midprogram report. ISP grants must provide a midprogram report when an RSP grant application is being prepared and submitted. Summary of ISP Activities Please answer the following questions to summarize ISP activities for the program as a whole. Describe the primary emphasis of outreach and services during the immediate services phase (e.g., individual or high-intensity services to survivors and the most heavily impacted communities or at-risk populations).	(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 your plan for securing office space for this project. (27) CCP requires mandatory training during the RSP. Please describe the 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.
p. 10	Describe the services provided during the ISP, including a discussion of any trends or key issues based on analysis of the ISP data. Highlight any prevalent or key issues or disaster reactions encountered during the first 2 months of services. Describe any issues or disaster reactions unique to specific communities or at-risk populations. Describe any issues or disaster reactions related to the type of disaster that occurred. Highlight any public education, media messaging, or educational materials distribution. Additional comments, if any: 2. ISP Data Tables Data Collection Totals: Please complete the following data tables, including total numbers for the entire ISP to date. The State may replace these tables by inserting or attaching database reports from the CCP Online Data Collection and Evaluation System, as long as all required indicators are included.	(28) Does the Grantee have experienced in-state trainers who can provide training on the CCP model? Yes or No Part VI: Budget (29) Attach Standard Form 424 Request for Federal Assistance (SF–424) and Standard Form 424a Budget Information: Non-Construction Programs. The 424 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 Lobbying YES or NO Drug-Free Workplace YES or NO Debarment and Suspension YES or NO (32) The Governor or Tribal Chief Executive certifies the following: The requirements are beyond the State, 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, Territory or Indian Tribal government will maintain close coordination with and provide reports to the Regional Administrator, the Assistant Administrator for the Recovery Directorate and the Secretary. (33) By signing below the GAR or Tribal Chief Executive affirms that the foregoing questions have been answered correctly and truthfully to the best of their knowledge. PART VIII -Application Checklist (34) The following documents have been submitted with this application: Completed ISP Application (Form 1660-0085) YES or NO Request for Federal Assistance (SF 424) YES or NO Budget Information – Non Construction Programs (SF 424A) YES or NO Budget Narrative YES or NO Organizational Chart YES or NO Assurances forms in Question 31 above YES or NO ISP Mid-program report (if applicable)
Pgs 11-26		These questions are now removed