PART II: PLAN OF SERVICE/NEEDS ASSESSMENT

PAPERWORK BURDEN DISCLOSURE NOTICE

PRIVACY ACT STATEMENT

PART I: GENERAL APPLICATION INFORMATION

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. 

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, 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.

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. 

4. State, Tribal Government or Territory requesting services:

5. Primary Point of Contact (POC) information for the administration of this program.

5a. POC Name:

5c. POC Mailing Address:

5d. POC E-Mail Address:

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. 

DEPARTMENT OF HOMELAND SECURITY 

Federal Emergency Management Agency 

APPLICATION FOR CRISIS COUNSELING PROGRAM SERVICES 

(IMMEDIATE SERVICES PROGRAM)

OMB. Number: 1660-0085 

Expires 03-31-2026

5b. POC Organization:

FEMA Form FF-104-FY-21-148 (formerly 003-0-1) (12/22) Page 1 of 4

1. Request Date: 2. Declaration #: 3. Declaration Date:

6. Amount requested for Immediate Services Program (ISP) funding (please round to nearest dollar). 

5e. POC Phone Number
8. Estimated Population to be served:

OPTION A: Federal award applicants 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 proposed 

providers number of direct and non-direct 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. Multiply the total census by the 

"percentage impact factor of .0075" by the "total census population" to arrive at an estimated population to be served during the ISP. 

Please also list the number of direct and non-direct 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 FTE's (Crisis 

Counselors, Team 

Leads) (Typically a 

300:1 ratio)

Number of Non-Direct 

Staff FTE's (Admin., 

Fiscal, Data etc.) 

Typically 15-20%

TOTALS: -

FEMA Form FF-104-FY-21-148 (formerly 003-0-1) (12/22)

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.

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PART III: RESPONSE ACTIVITIES

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.

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.).

FEMA Form FF-104-FY-21-148 (formerly 003-0-1) (12/22) Page 3 of 4

10a. Does the State, Tribal Government or Territory have experienced CCP trainers? Yes No

11. Please describe any mental health-specific response activities undertaken from the date of incident to the date of application. 
PART VI: APPLICATION CHECKLIST

PART IV: BUDGET

PART V: ASSURANCES

f. Lobbying forms, if not on file with FEMA

The State, Tribal Government or Territory will maintain close coordination with and provide reports to the Regional Administrator.

15. 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.

16. The following documents have been submitted with this application:

a. Completed ISP Application

b. Request for Federal Assistance (SF-424)

c. Budget Information - Non-Construction Programs (SF-424a)

d. Assurances for Non-Construction Programs (SF-424b)

e. Budget Narrative

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

health planning.

FEMA Form FF-104-FY-21-148 (formerly 003-0-1) (12/22)

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 crises 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.

14. By signing below, the Governor or Chief Tribal Executive agrees to and/or certifies that:

The requirements are beyond the State, local, 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.

No

Yes

No

Yes

No

Yes No

Yes

No

Yes

No

Yes

Signature Date

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