Project # 

Weekly Tally Sheet

OMB NO. 0930-0270 

Expiration Date 08/31/2025

Brief Educational and Supportive Services Not Elsewhere Included

Provider Name

County or Parish Provider Number

Week beginning mm/dd/yyyy Employee ID

Note: If the number is zero, the field may be left blank.

TYPE OF CONTACT NUMBERS OF CONTACTS OR NUMBERS DISTRIBUTED

SUN. MON. TUE. WED. THU. FRI. SAT. TOTAL

In-person or virtual brief 

educational or supportive contact

Telephone contact by crisis 

counselor (outbound calls to 

participants)

Hotline/helpline/lifeline contact

(inbound calls from participants)

Electronic interaction (email, text, 

chat, direct messages, etc.)

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 emailed, mailed, 

and/or left at a person’s

unattended home

Material left in public places

Mass media

Social media posts

Social media impressions/reach

Social media engagement
INSTRUCTIONS: WEEKLY TALLY SHEET

BRIEF EDUCATIONAL AND SUPPORTIVE SERVICES NOT ELSEWHERE INCLUDED

When To Use This Form:

This sheet is intended to capture all the contacts you have had for a particular week that have not been captured on anyother 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.

PROVIDER NAME—The name of the program/agency. 

COUNTY OR PARISH OF SERVICE—The county or parish where the service occurred. 

PROVIDER NUMBER—The unique number under which your program/agency is providing services. 

WEEK BEGINNING mm/dd/yyyy—The date of the first week day in the format mm/dd/yyyy, e.g., 01/01/2021. 

EMPLOYEE #—YOUR employee number issued by ODCES (must be numeric and no more than 6 digits).

NUMBERS OF CONTACTS OR MATERIALS DISTRIBUTED—For each day of the week, fill in the total number of contacts for each of the

following types:

IN-PERSON OR VIRTUAL BRIEF EDUCATIONAL 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 made by a crisis counselor to 

participants that did not result in in-depth discussion or interaction of an educational or crisis counseling nature. Record this contact on 

the WeeklyTally 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 participants made to 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.)

ELECTRONIC INTERACTION—The number of brief electronic contacts (e.g., email, text, chat, direct messages) with 

individuals that did not result in in-depth discussion or interaction of an educational or crisis counseling nature. Each

conversation/thread is counted once on the day it starts, even if the conversation happens over multiple days and/or with 

multiple people. 

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, faithbased 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 EMAILED, MAILED, AND/OR LEFT AT A PERSON'S UNATTENDED HOME—How many packets or materials were emailed, 

mailed, and/or left at people's homes when they were not there (with no interaction with the recipients or 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 (CCP), 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 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 broadcast.

SOCIAL MEDIA POSTS—How many messages did you post via social media (e.g.,Facebook or Twitter)? Do NOT include the number of 

replies or posts made by outside parties.

SOCIAL MEDIA IMPRESSIONS/REACH—How many people and entities saw the social media post?

SOCIAL MEDIA ENGAGEMENT—How many people/entities engaged with the social media post (e.g., likes, reposts, detail expands, 

profile clicks)? Engagement for a post should only be recorded once (typically about 48 hours after the post goes live). 

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 the Federal Emergency Management Agency’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 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 Lane, Room 15E57B, Rockville, MD 20857.