Access data collection forms and survey templates to evaluate your Crisis Counseling Assistance and Training Program (CCP), and learn how to use them.
Crisis counselors are required to document the services they provide. Collecting data on disaster survivors and the services they receive supports ongoing evaluation of your Crisis Counseling Assistance and Training Program (CCP).
Basic Data Collection Forms and Training
There are three basic forms submitted to CCP team leaders after each encounter:
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
- Individual/Family Crisis Counseling Services Encounter Log (OMB 2022) (PDF | 177 KB)
- Group Encounter Log (OMB 2022) (PDF | 237 KB)
- Weekly Tally Sheet (OMB 2022) (PDF | 245 KB)
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
- Individual/Family Crisis Counseling Services Encounter Log (PDF | 313 KB)
- Group Encounter Log (PDF | 57 KB)
- Weekly Tally Sheet (PDF | 75 KB)
Access the Basic Forms Training for crisis counseling staff to learn how to fill out each one. The webinar is about 55 minutes. CCP Data Forms: Frequently Asked Questions (PDF | 209 KB) is also helpful.
These forms are also available in Spanish:
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
- Registro de visitas para los servicios de consejería de crisis para las personas individuales o las familias (OMB 2022) (PDF | 215 KB)
- Registro de la visita de grupo (OMB 2022) (PDF | 188 KB)
- Hoja de computo semanal (OMB 2022) (PDF | 305 KB)
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
- Registro de visitas para los servicios de consejería de crisis para las personas individuales o las familias (PDF | 107 KB)
- Registro de la visita de grupo (PDF | 104 KB)
- Hoja de computo semanal (PDF | 186 KB)
Assessment and Referral Tools and Training
Service providers also use advanced tools known as assessment and referral tools.
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
- Adult Assessment and Referral Tool (OMB 2022) (PDF | 296 KB)
- Adult Assessment and Referral Tool Response Card (PDF | 159 KB)
- Child/Youth Assessment and Referral Tool (OMB 2022) (PDF | 364 KB)
- Child/Youth Assessment and Referral Tool Response Card (PDF | 74 KB)
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
- Adult Assessment and Referral Tool (PDF | 98 KB)
- Adult Assessment and Referral Tool Response Card (PDF | 159 KB)
- Child/Youth Assessment and Referral Tool (PDF | 61 KB)
- Child/Youth Assessment and Referral Tool Response Card (PDF | 74 KB)
These forms are also available in Spanish:
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
- Herramienta para la Evaluación y Referido de Adultos (OMB 2022) (PDF | 214 KB)
- Herramienta para la Evaluación y Referido de Adultos Tarjeta de Repuestas (PDF | 64 KB)
- Herramienta para la Evaluación y Referido de Niños y Jóvenes (OMB 2022) (PDF | 302 KB)
- Herramienta para la Evaluación y Referido de Niños y Jóvenes Tarjeta de Repuestas (PDF | 62 KB)
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
- Herramienta para la Evaluación y Referido de Adultos (PDF | 174 KB)
- Herramienta para la Evaluación y Referido de Adultos Tarjeta de Repuestas (PDF | 64 KB)
- Herramienta para la Evaluación y Referido de Niños y Jóvenes (PDF | 150 KB)
- Herramienta para la Evaluación y Referido de Niños y Jóvenes Tarjeta de Repuestas (PDF | 62 KB)
These tools collect data on people who are experiencing serious reactions, or who have encountered service providers three or more times. Training on how to use assessment and referral tools is presented in three parts:
- Section 1 provides an overview of CCP assessment and referral tools and their purpose. This training is about 10 minutes.
- Section 2 explains how to complete the Adult Assessment and Referral Tool and how to use the results to make appropriate referrals. This training is about 20 minutes.
- Section 3 explains how to complete the Child/Youth Assessment and Referral Tool and use the results to make appropriate referrals. This training is about 30 minutes.
Feedback Surveys and Forms
Feedback from disaster survivors and service providers helps grantees improve CCP services in real time and keep program goals on track.
Participant Feedback
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
Use the Participant Feedback Survey (OMB 2022) (PDF | 255 KB) to collect feedback from disaster survivors who have received CCP services. This survey is also available in Spanish (OMB 2022) (PDF | 285 KB).
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
Use the Participant Feedback Survey (PDF | 84 KB) to collect feedback from disaster survivors who have received CCP services. This survey is also available in Spanish (PDF | 219 KB).
Use the following resources to help you collect feedback from CCP participants:
- Participant Feedback Survey: Guidelines for Trainers (PDF | 115 KB)
- Participant Feedback Survey: Guidelines for Counselors (PDF | 97 KB)
- Participant Feedback Survey: Cover Letter (DOC | KB)
Service Provider Feedback
Please use the following forms if your ISP or RSP began on or after April 1, 2020.
Use the Service Provider Feedback Form (OMB 2022) (PDF | 340 KB) to collect feedback from CCP crisis counselors. This survey is also available in Spanish (OMB 2022) (PDF | 209 KB).
Please use the following forms if your ISP or RSP began on or before March 31, 2020.
Use the Service Provider Feedback Form (PDF | 148 KB) to collect feedback from CCP crisis counselors. This survey is also available in Spanish (PDF | 203 KB).
Use the following resources to help you collect feedback from CCP service providers:
- Service Provider Feedback Form Task Timeline (PDF | 212 KB)
- Boilerplate Service Provider Feedback Form Announcement (DOCX | 23 KB)
- Boilerplate Service Provider Feedback Form Announcement: Paper Version (DOCX | 24KB)
- Boilerplate Service Provider Feedback Form Cover Letter (DOCX | 31 KB)
- Boilerplate Service Provider Feedback Form Cover Letter: Paper Version (DOCX | 33 KB)
- Boilerplate Service Provider Feedback Form Thank You/Reminder (DOCX | 24 KB)
