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Evaluation Guide - CCP Evaluation Online Database

1. No w How much has your crisis counseling work or your reactions to it affected your relationships with your family or friends or interfered with your social recreational or community activities es 1 2 3 4 How distressed or bothered are you about your reactions z len o If you answered some of these questions with a 4 or 5 you might want to talk with a counselor about your reactions If you have concerns about your answers to these questions please call These final questions will help us to describe the total group of people who completed the survey How many hours of crisis counseling program less than 20 20 29 30 39 40ormore work do you do in a typical week How many months have you worked with the crisis counseling program If less than one month please enter 0 Do you supervise the work of other crisis counselors no yes What county or parish do you work in mostly PLEASE PRINT YOUR ANSWER NEATLY IN CAPITALS gt gt gt Vhat is your sex male female How old are you Vhat was the highest year of school that you completed lessthan high school highschool graduate some college college graduate masters degree doctoral degree Which race bests describes you Select one or more American Indian Alaska Native Asian Black or African American Native Hawaiian Pacific Islander White Are you Hispanic Latino no T yes Do you h
2. DEMOGRAPHIC INFORMATION Age select one Sex select one Race select one or more Ethnicity select one preschool 0 5 male American Indian Alaska Native Hispanic or Latino child 6 11 female Asian Not Hispanic or Latino adolescent 12 17 Black or African American Primary Language of Contact select one Native Hawaiian Pacific Islander English Spanish Grade Level in School White other specify gt PLEASE CONTINUE ON PAGE 2 ON BACK Child Youth Assessment amp Referral Tool page 2 ASSESSMENT QUESTIONS INTRODUCTION want to talk to you about your your child s feelings and thoughts about the disaster and how much they are causing problems now Think about your thoughts feelings and behavior DURING THE PAST MONTH please remind child parent of this for each question Use the frequency rating options on the next page and on the response card to help the child answer how often the problem has happened in the past month For each question choose ONE of the following responses and check the appropriate box for that question 0 notatall 1 a little bit 2 somewhat 3 quite a bit 4 very much z 0 1 2 3 4 1 Do you get upset afraid or sad when something makes you think about the disaster 0 1 2 3 4 2 Do you have bad dreams or nightmares about what happened E 0 1 2
3. RISK CATEGORIES select all that apply family missing dead friend missing dead pet missing dead home damage vehicle or major property loss EET ta E other financial loss injured or physically harmed self or household life was threatened self or household witnessed death injury self or household assisted with rescue recovery self or household disaster unemployed self or household had to change schools for children or youth evacuated quickly with no time to prepare prolonged separation from family displaced from home 1 week or more past substance use mental health problem pre existing physical disability past trauma DEMOGRAPHIC INFORMATION Age select one Sex select one Race select one or more Ethnicity select one preschool 0 5 male American Indian Alaska Native Hispanic or Latino child 6 11 female Asian not Hispanic or Latino adolescent 12 17 Black or African American Primary Language of Contact select one adult 18 39 Native Hawaiian Pacific Islan der English adult 40 64 White Spanish adult 65 other specify in box gt EVENT REACTIONS select all that apply BEHAVIORAL EMOTIONAL PHYSICAL COGNITIVE Extreme change in activity level Sadness tearful Headaches Distressing dreams nightmares Excessive drug or alcohol use Irritable angry Stomach problems Intrusive thoughts images Isolation withdrawal Anxious fearfu
4. The 3 digit FIPS code for the county where the service occurred ZIP CODE OF SERVICE The zip code of the location where the service occurred LOCATION OF SERVICE Where did you provide the service SELECT ONLY ONE VISIT TYPE Vas this encounter with one person or with two or more related individuals family Please complete one form for each active participant If the encounter was with two or more unrelated individuals use the group counseling form VISIT NUMBER Based on your conversation with the individual is this the 15t 274 3 4th 5 or more visit for this person to your program All visits did not have to be with you SELECT ONLY ONE RISK CATEGORIES These are factors that an individual may have experienced or may have present in their life that could increase their need for services MORE THAN ONE CATEGORY MAY APPLY SELECT ALL CATEGORIES THAT APPLY DEMOGRAPHIC INFORMATION For each variable SELECT ONLY ONE AGE The age you perceived the person to be SELECT ONLY ONE GRADE LEVEL Please enter the number e g 4 4th grade SEX Was the person male or female SELECT ONLY ONE RACE Based on your observations and your conversation with the individual what race would this person identify himself or herself as being SELECT ALL THAT APPLY ETHNICITY Based on your observations and your conversation with the individual does this person self identify as Hispanic Latino SELECT ONLY ONE PRIMARY LANGUAGE OF CONTACT
5. Please approach the survey positively and be assured that it is not a burden to participants Many people will appreciate the opportunity to give back This is a healthy thing As always we count on your expertise and your exceptional ability to engage people We can t wait to share the results with you which we are sure will help us to show how good a job we are all doing while also giving us some guidance about how to further improve Thank you for this and everything you do Al SAMHSA DTAC Y Y S Component HI Crisis Counseling Assistance and Training Program CCP Online Data Collection and Evaluation System User Manual Version 2 0 SAMHSA DTAC 4 Online Data Collection and Evaluation System User Manual Version 2 0 SAMHSA DTAC gt Online CCP Data Collection amp Evaluation System User Manual Table of Contents AAT Section 1 INTRODUCTION ooooocccccccnccnnocnnoccnonononononnncnonononncnnnnonnnonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnns 2 1 1 SYSTEM ACCESS AND LOGIN cooocccccococononoconnnnnnnnnononccnnnnnnnnnnnnnnn cess ee eesecaacaeceeeeeeesecacaeeeeeeeeesensucaeeeeees 2 1 2 SYSTEM SUPPORT sousniicadin sata dida 2 AAT Section 2 SYSTEM OVERVIEW 00 ccc cccccccccccccssccssecssecssecssescsesessecssescsescseeceeecsaecsaecaeesseeseecseeens 3 2 1 USER ACCESS LEVELS erien narani a aaa o aE ea a Iii tancia tdi iii 3 2 2 SYSTEM ORGANIZATION iecicisceccccssnececvatancscvsdancedestendscdsnndedvarnad
6. While outputs assess how much was done outcomes focus on how much good was done Outcomes can be considered in the short immediate intermediate and long term Immediate outcomes are those that can be observed directly after completing an activity Intermediate outcomes are those that derive from immediate outcomes such as alleviation of symptoms reduced substance use or improved functioning in family community professional and other social roles Long term outcomes may include community cohesion increased disaster preparedness or community resilience in dealing with subsequent crisis AAG Evaluation for CCPs What are the goals The evaluation of a CCP answers questions about three critical areas of performance 1 program reach 2 program quality and 3 program consistency Whatis program reach How many people in the community were served by the CCP and what were their characteristics The CCP aims to deliver services to large numbers of residents who are diverse in age ethnicity and needs This aspect of the evaluation makes use of data from encounter logs and tallies that are routinely completed by counselors The question is not only about the actual numbers of people served but also about how well these numbers align with the distribution of the State s population in the affected areas What is program quality W ere the services perceived as appropriate and beneficial by disaster survivors and providers To
7. appears at the bottom of each form page All of these methods should be familiar to most computer users However if you have difficulty with your data entry and would like to restart a form you can clear the data already entered and start over simply by clicking on the Reset Form button on the bottom of the form page DO NOT use this method to delete a record Once you submit a form a confirmation page is generated This page supplies feedback on the data you just submitted You can review what has been submitted and can opt to return to the form using the link provided to update any data as necessary DO NOT use the Back button on your browser to return to the form doing so will create a duplicate record User Manual Version 2 0 Page 11 of 15 SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual REQUIRED FIELDS Throughout the system you will see the asterisk symbol which has been used to indicate when a field is required As has already been mentioned in the Validation section under Section 2 3 Special Features the system was designed to be as accommodating as possible to data entry Therefore a number of fields are marked as required but will still accept a blank entry or null value unless indicated by a red validation error at the top of the page However while a blank value is allowed in some instances itis not ideal from the standpoint of data analysis and reporting Therefo
8. brief supportive or educational encounter on the Weekly Tally Sheet or public education on the Group Encounter Log and it is not given if the counseling occurred over the telephone The survey is also not for people less than 18 years of age When should you give the person the packet Introduce the survey when your conversation is starting to wind down but before the person is rushing off to the next thing he or she needs to do What should you say when giving someone the packet Use your own words but you can basically say the same thing that the cover letter says 1 that name of project is trying to help people cope with the stress of the disaster 2 that to do your jobs well it is helpful to learn more about how people are doing now and about whether crisis counselors are finding the best ways to be helpful and 3 that this packet has a very brief survey that will take them only a few minutes to fill out but will be very helpful to the project Appeal to their altruism The survey really is short and people who have been through a serious event understand why it is useful to ask them about it and the services your program is providing to support them in coping with the event You can also point out that everything they need is inside the packet the survey a pen and a stamped envelope to use to mail it back in You should mention that the survey doesn t ask for their names and is completely anonymous What should you do if t
9. oooooooocccccccccccocononoconcnonnnnnononnnnnnnnnnnnnnnnnnnnnnnnnnnn nn nn cnnrnnnnnns 14 Baad Section 4 RESOURCES isis cscsccazteeae acces ii a aaaea aaea Eti Taaa aaa A a AER 15 4 1 OFFICE OF MANAGEMENT AND BUDGET OMB CLEARED CCP FORMS ddococccccccncacanoncnnnnnnos 15 4 2 TRAINING MATERIALS veriviiceccivasccudavabacetvvaccenevvanccedhyvanseutuvancceey EEREN EA AEAEE aaa 15 ADATA DICTIONAR Nese ees se tates ceed esc ed daw ere eda ren sae ed cate ck ea enc con ae Peay eneeetees 15 User Manual Version 2 0 Page 1 of 15 DEJO SAMHSA DTAC Online CCP Data Collection a Evaluation System User Manual 4A GT Section 1 INTRODUCTION This manual provides an overview of how to use the Crisis Counseling Assistance and Training Program CCP Online Data Collection and Evaluation System The system allows CCP data to be entered and maintained and provides for multiple levels of user access Required and ad hoc reports can be generated in a variety of formats Users are better able to analyze track and report on the various activities occurring in a CCP This manual provides information on accessing the system user access levels system organization special features setting up a disaster CCP profile entering and maintaining data generating reports and resources Data collection and evaluation are crucial elements of the CCP and serve a number of purposes Program evaluation refers to systematic efforts to collect analyze and interpret
10. or reaction section of the tool page 2 items 1 20 was adapted from the University of California Los Angeles UCLA Post traumatic Stress Disorder PTSD Reaction Index Steinberg et al 2004 with inclusion of additional items related to depression and functioning Drs Pynoos and Steinberg granted permission for this modification for use by the CCP Project Liberty after the terrorist attacks on September 11 2001 This tool was then further modified for use by the Louisiana Spirit Specialized CCP after Hurricanes Katrina and Rita National Child Traumatic Stress Network 2005 20 SAMHSA DTAC Is the measure good Using this referral tool over 70 percent of children and adolescents initially screened for the Louisiana S pirit Specialized CCP and given a referral accepted the referral Riise et al 2010 This finding was slightly higher than that in Project Liberty 60 percent of children referred accepted the referral which used an earlier version of the assessment tool For the referral tool in general items had good internal consistency and showed a strong relationship with referral acceptance Kronenberg etal 2010 How is it scored The tool is scored by counting the number of items page 2 questions 1 20 that have a value of 3 quite a bit or 4 very much The tool has been structured in a way that makes the scoring straightforward If the total number is four or higher the counselor should discuss appropriate re
11. possibility of a referral for more services For children over the age of 10 or if the crisis counselor or parent caregiver is concerned about a younger child the counselor may ask Have you had any thoughts or plans about either hurting or killing yourself If the respondent answers YES to this item then the crisis counselor should immediately refer the child youth for psychiatric or mental health professional intervention The CCP should have protocols or procedures in place for how a crisis counselor should respond and who should be notified of this safety concern Many CCPs have team leaders or other staff with a mental health background to ensure that proper assessment and referral is carried out All crisis counseling staff using this tool should have detailed training and guidance on use of the tool and when to make a referral for more intensive services Prior to use of this tool the CCP should have identified an organization or agency that is willing to accept referrals from the CCP for more immediate psychiatric intervention Referral Component If the total number is four or higher the counselor should discuss appropriate referral options for the child youth and or family This includes being prepared to offer youth and parents the name atan organization that has agreed to accept CCP referrals and a contact at that organization If the total number is three or less the counselor can recommend either another visit with him o
12. 3 4 3 Do you have upsetting thoughts or pictures that come into your mind about what happened 0 1 2 3 4 4 Do you try not to think about or talk about what happened p 0 1 2 3 4 5 Do you stay away from places people or things that make you remember the disaster 0 1 2 3 4 6 Do you have difficulty falling asleep or wake up often because of what happened 1 2 3 4 7 Do you feel jumpy or nervous 0 aes 0 1 2 3 4 8 Do you find it harder to concentrate or pay attention to things than you usually do 1 2 4 9 Do you feel irritable or grouchy r 3 0 1 2 3 4 10 Do you feel sad down or depressed 0 1 2 3 4 11 Have you had more aches and pains such as stomachaches or headaches p 0 1 2 3 4 12 Ifin school Do you find it harder to get your schoolwork done 5 y 0 1 2 3 4 13 Do you worry about something else bad happening to you your family your frends z a 0 1 2 3 4 14 Are you having a harder time getting along with family or your friends a ere 0 1 2 3 4 15 Are you finding it harder to do or enjoy activities that you used to enjoy E ADDITIONAL QUESTIONS FOR PARENTS Required for parents of children aged 0 7 recommended for parents of all children and adolescents 1 2 4 16 Has your child been more clingy or worried
13. Disorder Rating Interview SPRINT developed by Connor and Davidson With the permission of Connor and Davidson the measure was modified for the CCP Project Liberty s use after the terrorist attacks of September 11 2001 SPRINT expanded or Sprint E The Sprint E assesses posttraumatic stress health risk behavior stress vulnerability and functional impairment One final question was added Is there any possibility that you might hurt or kill yourself but is not included in the score Rather it was included in the scale as a precaution and instructs the crisis counselor to refer the respondent for immediate psychiatric intervention Is the measure good Data from 788 clients in Project Liberty indicated that the Sprint E is a reliable measure of need for intervention as expressed in distress and dysfunction Of those offered referral according to their score on the tool 71 percent accepted Among those offered referral the number of intense reactions was by far the strongest predictor of referral acceptance Many of the attributes of the Sprint E brevity simplicity of administration focus on intense reactions emphasis on function and subjective need emerged because it was developed collaboratively by researchers and leaders of Project Liberty In a study of 800 adults in crisis counseling two years after 9 11 the Sprint E was found to be equally reliable 93 across ethnic groups in the sample A criterion of three intense reacti
14. Survey Participant Feedback Survey Resources Reports Logout ENTERING DATA State level or provider data entry staff may enter form data by simply selecting a form from the left side navigation bar and then entering the base data for that particular form This base information correlates directly to the paper CCP form and typically includes the minimal required information such as project number provider name date of service and county code of service Once entered this base information will be auto populated into each new instance of this form that you create during this particular data entry session See Redundant Field Auto Population in Section 2 3 You can change the base information at any point when you need to do so Please Note The base data entry fields are contingent on each other for data population in some cases For example you must first identify a project number from the drop down list provided that action will populate the provider name and the county code of service drop down lists based on the project number identified and once a provider name is identified the provider number is automatically populated next to that field The data fields for each form are identical to the fields on the paper CCP forms Data are collected in a variety of formats such as radio buttons checkboxes drop down lists text entry fields etc and are submitted to the database by clicking on the Submit button that
15. Survey Service Provider Feedback Survey Standard Progress Report This report provides data for disaster outreach services individual encounter by age and monthly trends for individual group encounters and risk factors CCP Evaluation Online Database Download Data for the following data sets can be downloaded to a comma separated values CSV file or to a text file for use with a Statistical Package for the Social Sciences SPSS application Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally Sheet Adult Assessment and Referral Tool Child Youth Assessment and Referral Tool Participant Feedback Survey Service Provider Feedback Survey User Manual Version 2 0 Page 4 of 15 DEJO SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual 2 3 SPECIAL FEATURES This system was developed with user friendly features that will allow users to avoid redundant data entry tasks improve data accuracy and obtain information and feedback These features are described below ADMIN VIEW The Admin section of the system provides you with a quick at a glance view of the last five records submitted for each form in real time Please Note The Provider Survey form is not included in this section because it is only accessible for viewing after the external evaluation consultant has entered and locked down the data AUTO CALCULATIONS Forms requesting totals entered into
16. a contact where the discussion goes beyond education and assists persons to understand their current situation and reactions review options or address their emotional support or referral needs 3 This form is also to be used for families Complete a single form for each member of the family that participates in receives crisis counseling For example a husband and wife along with their two children attend an individual crisis counseling session The husband and wife actively participate with the crisis counselor but the children sit quietly You must complete one form for the husband and a separate form for the wife 4 This form is not intended to be used as a survey Do not ask the individual for any of the information on this form Complete all items on the form based on your best observations and information you received during the encounter community services e g FEMA loans housing employment social services PROJECT FEMA disaster declaration number Example DR XXXX State PROVIDER NAME The name of the program agency PROVIDER The unique number your program agency is providing services under EMPLOYEE YOUR employee number DATE OF SERVICE The date of the encounter in the format MM DD YYYY e g 01 01 2008 COUNTY CODE OF SERVICE The 3 digit FIPS code for the county where the service occurred ZIP CODE OF SERVICE The zip code of the location where the service occurred LOCATION OF SERVICE Where did you provide
17. assess service quality consumer feedback is essential This aspect of the evaluation relies upon brief anonymous surveys that capture service recipients perceptions of service quality and personal improvements in functioning More detail about how this is done will follow Disaster survivor feedback can also help program managers reach a better understanding of factors that influence recipients perceptions of service quality Because a different perspective on service quality can be obtained from service providers the evaluation also includes a survey for crisis counselors and their supervisors Whatis program consistency Many CCPs involve multiple jurisdictions such as counties parishes ortownships and many involve collaborative arrangements with provider organizations Did these areas or providers vary in performance i e reach and quality and can this be explained by differences between them in population and experiential characteristics Finding that some providers yield higher reach in proportion to population recipient satisfaction and or provider satisfaction will inform project managers that further study or corrective action is needed Advanced analyses can also contribute to knowledge about characteristics of settings e g low population density and events that make it more challenging to implement the CCP A Y Y Data Collection with the CCP Data Forms What are the sources of data Evaluation data come from many dif
18. certain fields will auto calculate for you This feature will allow for more accurate data entry Type of Contact SUN MON TUE WED THU FRI SAT TOTAL educttional or supportive JET E Tr Jf lo 1 contact Telephone contact 7 P 7 Fo 7 Fo ml 49 Number of Participants please estimate E 7 119 Number age lt 18 j2 Number age 18 64 12 Number age 65 12 mi 189 EOIN 3 Gute saltas bowed on your FORT 1 Bbo 121 person s home Fasa left in public Po az 7 7 Fo ma 49 ther ki 40 ae EE F E r ee By clicking on the below button Totals will be auto calculated for the respective Type o Contact Calculate Total for the contacts User Manual Version 2 0 Page 5 of 15 DO SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual CONTEXTUAL HELP ICONS Throughout the form pages you will see small information icons with the letter i next to data entry fields You can click these icons to reveal helpful information about that particular data point DEMOGRAPHIC rnronnarrce El Age adult 18 39 adult 40 64 C Oebiition WINE ACI Term Definition Sex CEMOGRAPHIC for each vaneble SELECT ONLY ONIL The Adult male C female INFORMATION Ascecement and Relarral Tool ie an interview guide and you mey ask ask the individual these questions as needed Note this instruction is not the seme as for the dd Individual Crisis Counseling Serv
19. damaged or destroyed assisted with rescue recovery self or household past substance use mental health problem vehicle or major property loss disaster unemployed self or household pre existing physical disability other financial loss past trauma Age select one Sex select one Race select one or more Ethnicity select one adult 18 39 male American Indian Alaska Native Hispanic or Latino adult 40 64 female Asian not Hispanic or Latino adult 65 Black or African American Primary Language of Contact select one Native Hawaiian Pacific Islander English White Spanish other specify in box gt PLEASE CONTINUE ON PAGE 2 ON BACK Adult Assessment amp Referral Tool page 2 ASSESSMENT QUESTIONS GIVE RESPONSE CARD TO RECIPIENT READ These questions are about the reactions you have experienced IN THE PAST MONTH By reactions mean feelings or emotions or thoughts about the events For each question choose one of the following responses from this card 1 notatall 2 a little bit 3 somewhat 4 quite a bit 5 very much QUESTIONS TO BE READ RESFONDENT A ANSWER 1 2 3 4 5 1 How much have you been bothered by unwanted memories nightmares or reminders of what happened nm nm nm E W 2 How much effort have you made to avoid thinking or talking about what happened or doing things that 1 2 3 4 5 remind you of wha
20. is not feasible to measure client outcomes assessing client perceptions is the next best approach The survey questions were informed by findings that disaster behavioral health services should be evaluated on the basis of their credibility acceptability accessibility and confidentiality among other characteristics Second the survey provides the program with excellent information about the experiences and reactions of people they aim to serve in individual and group crisis counseling It is one of the most important clinical records of the program This information could lead to program adjustments to meet previously unrecognized needs Third the survey helps planners learn about factors that influence perceptions of service quality For example are highly distressed individuals more or less positive about services than are less distressed individuals Are members of different ethnic groups equally likely to report that they were treated with respect and sensitivity To whom is the survey given The questionnaire is given to a sample of persons for whom individual or group crisis counseling services were provided i e not for persons denoted only on a tally sheet or who participated in group public education activities It is given only to adults The reading level is approximately 5th to 6th grade When is the survey done The survey is implemented at 6 and 12 months post event These time points typically occur within the RSP Once
21. leader receives completed forms from crisis counselors he or she should review the forms for completeness and validity In the reviewer signature block the team leader prints and signs his or her name and adds a date to the reviewer signature block to show when the form was reviewed When is it filled out The crisis counselor completes the Individual Encounter Log after the session is over but before moving to the next activity This should take no more than 2 minutes Waiting until the end of the day to fill the logs out is not acceptable because the crisis counselor will not remember the answer to each question Some people are seen more than once by a crisis counselor The log is filled out for all counseling visits not only the first one and the visit number is noted Completed logs should be turned into the team leader for review at the end of each day or the beginning of the following day Once the team leader has reviewed forms they should be submitted to the lead data staff person for entry into the CCP Online Data Collection and Evaluation System How does the crisis counselor get the information for the Individual Encounter Log Through active listening the crisis counselor engages the service recipient in telling his or her story in a way that reveals stressful experiences risk factors during or after the disaster Some of the demographic characteristics e g age might be elicited by asking the person about how his or her family is
22. little time to complete The three types of forms that are to be completed by crisis counselors include 1 Individual Crisis Counseling Services Encounter Log 2 Group Encounter Log and 3 Brief Educational and Supportive Services Not Elsewhere Included W eekly Tally Sheet or W eekly Tally Sheet for short Each is described below The forms and specific instructions are included in Component II of this toolkit Individual Crisis Counseling Services Encounter Log What is individual counseling Crisis counseling is brief and focused on reducing stress providing support and improving coping skills For the purposes of the data collection and evaluation individual crisis counseling is defined as an interaction that lasts at least 15 minutes and involves participant disclosure This doesn t mean that it should be only 15 minutes or that shorter interactions are discouraged There is a place on the form to record how long the particular encounter lasted What is in the Individual Encounter Log The Individual Crisis Counseling Services Encounter Log is a two page form with six parts Crisis counselors complete this form immediately after the encounter The crisis counselor is NOT expected to ask an individual for responses to these items rather crisis counselors complete the form based on their observations and interactions with the person during the encounter Part 1 Basic Information The first part collects information on the projec
23. meet once 1st session of group expect to meet more than once 2nd or greater session of ongoing group disaster recovery center e g FEMA ARC Todd place of worship e g church synagogue mosque gq aaa 0d NUMBER of PARTICIPANTS PLEASE ESTIMATE Number age lt 18 Number age 18 64 Number age 65 TOTAL DURATION 15 29 minutes 30 44 minutes 45 59minutes 60 minutes or more GROUP IDENTITIES select one Was the group composed ONLY or MOSTLY of any of the following children or youth lt age 18 CHECK if yes adult survivors adults who were directly affected by the disaster CHECK if yes public safety workers and first responders e g police fire EMS rescue CHECK if yes other recovery workers e g health care disaster relief social services CHECK if yes Was the group composed of a mixture of the above or none of the above i e no clear group identify CHECK if yes FOCUS of GROUP SESSION select all that apply education about reactions to disaster conflict resolution education about community resources community action mutual support information about CCP m stress management or skills building other specify in box gt PO Reviewer Name Signature Date of Review INSTRUCTIONS GROUP ENCOUNTER LOG When to Use This Form 1 Complete this form immediately after the group encounter is provided COMPLETE ONLY ONE FORM PER GROUP 2 Group sess
24. or interaction of an educational or crisis counseling nature EMAIL CONTACT This is the number of brief email contacts with individuals that did not result in in depth discussion or interaction of an educational or crisis counseling nature MATERIAL HANDED TO PEOPLE WITH NO OR MINIMAL INTERACTION How many materials were distributed by handing them out to people with no or minimal contact MATERIAL MAILED TO PEOPLE S HOMES AND OR LEFT AT A PERSON S HOME How many materials were mailed to people s homes and or left at at person s home MATERIAL LEFT IN PUBLIC PLACES How many materials were left in public places 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 STOP Please submit the completed form to the designated person in your agency who will review and sign the form Thanks for taking the time to complete this form accurately and completely OMB NO 0930 0270 PREG Adult Assessment amp Referral Tool Expiration Date 01 31 2012 Please use this tool as an interview guide 1 with adults who have received individual crisis counseling on two or more occasions before this visit OR 2 with any adult at any time if you suspect the adult may be experiencing serious reactions to the disaster Provider Name Provider Employee Date of Service mm dd yyyy County Code of Service Zip Code of Service CHARACTERI
25. questions with a 4 or 5 you might want to talk with a counselor about your reactions If you have concerns about your answers to these questions please call These final questions will help us to describe the total group of people who completed the survey What is your sex male female How old are you What was the highest year or grade of school that you completed 06 7 41 12 high school some college college graduate or more What county or parish do you live in now PO Which race bests describes you Select one or more American Indian Alaska Native Asian Blackor African American Native Hawaiian Pacific Islander White Are you Hispanic Latino no yes What is your preferred language English Spanish other specify in box gt Public Burden Statement 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 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 20 minutes per participant per year 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 suggestion
26. referrals It also helps to remind them that if individuals are not getting better they should and can be referred for more intensive help When and for whom are the assessment and referral tools used Because symptoms of distress may initially be highly prevalent in disaster stricken communities the focus is on continuing distress defined as high distress present 3 months or later after the event Typically the assessment and referral tools are introduced at the beginning of the RSP the tool is used with all adults and children or youth who are intensive users of services Intensive users are people who are participating in their third individual crisis counseling visit with any crisis counselor from the program or who continue to suffer severe distress that may be impacting their ability to perform routine daily activities In some cases the tool may be used again in the fifth session of crisis counseling Also there may be occasions when the crisis counselor believes the tool should be used before the third visit this is allowed but should be done sparingly Adult Assessment and Referral Tool What s in the Adult Assessment and Referral Tool Page 1 As with the other forms the first part may be pre filled to include basic information to collect information on the program such as project number FEMA disaster response number DR XXXX State provider name if not the State assigned provider number employee number service date county
27. the service SELECT ONLY ONE VISIT TYPE Was this encounter with one person or with two or more related individuals family Please complete one form for each active participant If the encounter was with two or more unrelated individuals use the group counseling form VISIT NUMBER Based on your conversation with the individual is this the qst 2nd 3rd ath 5th or more visit for this person to your program All visits did not have to be with you SELECT ONLY ONE DURATION How long did your encounter last SELECT ONLY ONE Ifthe encounter was lt 15 minutes record it on the Weekly Tally RISK CATEGORIES These are factors that an individual may have experienced or may have present in their life that could increase their need for services MORE THAN ONE CATEGORY MAY APPLY SELECT ALL CATEGORIES THAT APPLY DEMOGRAPHIC INFORMATION For each variable SELECT ONLY ONE AGE The age you perceived the person to be SELECT ONLY ONE SEX Was the person male or female SELECT ONLY ONE RACE Based on your observations and your conversation with the individual what race do you think the individual would identify himself or herself as being SELECT ALL THAT APPLY ETHNICITY Based on your observations and your conversation with the individual does this person self identify as Hispanic Latino SELECT ONLY ONE PRIMARY LANGUAGE OF CONTACT What language did you actually and primarily use to speak with this individual during the encounter Th
28. tool to ensure that proper assessment and referral is carried out All crisis counseling staff using this tool should have detailed training and guidance on use of the tool and when to make a referral for more intensive services Prior to use of this tool the CCP should have identified an organization or agency that is willing to accept referrals from the CCP for more intensive mental health or substance abuse intervention services If the answer to item 12 is NO then the crisis counselor should continue as follows 17 Al SAMHSA DTAC e If the total score is 3 or higher the counselor should be prepared to offer the respondent the name of the organization and a contact atthe organization that has agreed to accept CCP referrals e If the total score is below 3 the counselor then determines if the respondent can manage his or her reactions The counselor can still offer the referral information or can work with the person to decide upon specific goals for counseling that can be completing within a couple of visits The last part of the Adult Assessment and Referral Tool that the crisis counselor is to complete is similar to the referral section on the Individual Encounter Log The counselor will check what type of referral was provided and if the person accepted the referral How are adult symptoms assessed The symptom or reaction section of the tool page 2 items 1 through 12 was adapted from the Short Post Traumatic Stress
29. what it produces and what societal benefits it is trying to achieve This understanding is often termed a program theory or logic model A program logic model typically includes inputs activities outputs and outcomes as illustrated below The nature of the inputs activities outputs and outcomes however may depend upon characteristics of the disaster Such as its type and severity and characteristics of the community such as its density and wealth Figure 1 provides an example of CCP theory and logic model Ti SAMHSA DTAC Event Type of disaster Estimated need Outputs Activities Inputs Service mix Number of Grant type Referrals education amp Budget expenditures Training in advanced counseling contacts Other resources counseling issues Number of Diversity activities minorities served Number of Reduced stigma children served about seeking Number of elders treatment Community aave pesei paa Population density orientation Per capita income j Age amp ethnic distribution An example program theory and logic model bulleted items are illustrative not exhaustive Figure 1 Example of CCP Theory and Logic Model What are inputs Inputs are the resources available to the program for use in achieving its goals Some inputs are tangible resources funding program staff office space office supplies and other consumables transportation etc Others are less concrete but
30. 5 very much Ithas been structured in a way that makes the scoring straightforward Is the Individual Encounter Log used too Yes the crisis counselor should also complete the Individual Crisis Counseling Services Encounter Log as usual Some of the information is duplicated but the Individual Crisis Counseling Services Encounter Log and the Adult Assessment and Referral Tool are used for different purposes making it difficult to count these services solely from the Adult Assessment and Referral Tool 18 SAMHSA DTAC References Adult Assessment and Referral Tool Connor K Davidson J 2001 SPRINT A brief global assessment of post traumatic stress disorder International Clinical Psychopharmacology 16 279 284 Norris F Donahue S Felton C Watson P Hamblen J Marshall R 2006 A psychometric analysis of Project Liberty s Adult Enhanced Services Referral Tool Psychiatric Services 57 1328 1334 Norris F Hamblen J Brown L Schinka J 2008 Validation of the Short Post Traumatic Stress Disorder Rating Interview Expanded Version Sprint E as a measure of postdisaster distress and treatment need American J ournal of Disaster Medicine 3 201 212 Hamblen J L Norris F Pietruszkiewicz S Gibson L E Naturale A amp Louis C 2009 Cognitive behavioral therapy for postdisaster distress A community based treatment program for survivors of Hurricane Katrina Administrati
31. AA SAMHSA DTAC Evaluating and Monitoring the Reach Quality and Consistency of Crisis Counseling Assistance and Training Programs Toolkit Version 2 0 July 2011 CCP Administration Guide and Evaluation Toolkit revised J uly 2011 SAMHSA DTAC Contact Information for Questions or Comments Regarding Crisis Counseling Assistance and Training Program CCP Data Collection Forms and Evaluation Nikki D Bellamy Ph D Substance Abuse and Mental Health Services Administration SAMHSA Center for Mental Health Services CMHS Federal Project Officer 1 Choke Cherry Road 6th Floor Rockville MD 20857 Office 240 276 2418 Email nikki bellamyO samhsa hhs gov Contact Information for Questions or Comments Regarding the CCP Online Data Collection and Evaluation System Website SAMHSA Disaster Technical Assistance Center DTAC Toll Free 1 800 308 3515 Email DTACO samhsa hhs gov Technical Contributors Fran Norris Ph D with the National Center for Posttraumatic Stress Disorder U S Department of Veterans Affairs White River J unction VT Melissa Brymer Ph D with the National Center for Child Traumatic Stress University of California Los Angeles UCLA Alan Steinberg Ph D with the National Center for Child Traumatic Stress UCLA Los Angeles CA Patricia Watson Ph D with the National Center for Child Traumatic Stress UCLA Los Angeles CA Nikki D Bellamy Ph D with SAMHSA CMHS Brian McKernan M Ed ACADC w
32. ING THE PAST MONTH For each question choose one of the following responses from this card The response card is shown on page 3 of the Child Y outh Assessment and Referral Tool The response card is also located in Component II of this toolkit and the CCP Application Toolkit Responses to the questions in this section are as follows 0 Notatall 1 A little bit 2 Somewhat 3 Quite a bit and 4 Very much For questions 1 15 read each item aloud and have the child youth or caregiver identify how often the child has experienced these feelings thoughts or behaviors in the past month by pointing on the response card to the choice that best fits For younger children the crisis counselor may have to help the child understand how long a month has been by identifying something in the child s life that occurred a month ago e g a holiday school break tests or a family event Then the crisis counselor can say for example Since spring break then read the item 19 Al SAMHSA DTAC Questions 16 20 should be asked of a parent caregiver These questions are required for children aged 0 7 and recommended for all children and adolescents The response choices for these questions are the same as for questions 1 15 The crisis counselor fills in the respondent s answers to each item on this page and then totals the number of items that were scored 3 or 4 If the total number is four or more the crisis counselor should discuss the
33. STICS of ENCOUNTER LOCATION of SERVICE select one school amp child care all ages through college home temporary or permanent including friend or family homes group homes including houses apartments trailers and other dwellings community center e g government recreation social services Mm IF HOME PLEASE CHECK THIS BOX IF ANY provider site agency involved with CCP CHILDREN lt AGE 18 LIVE IN THIS HOME workplace e g office workers public safety phone counseling 15 minutes or longer including hot lines amp life lines disaster recovery center e g FEMA Red Cross medical center e g doctor dentist hospital mental health specialty place of worship e g church synagogue mosque public place event e g street sidewalk town square fair festival sports retail e g restaurant mall shopping center store other specify in box gt VISIT NUMBER 1stvisit 2nd visit 3rd visit 4th visit 5th visit or more DURATION 15 29minutes 30 44 minutes 45 59minutes 60 minutes or more RISK CATEGORIES select all that apply family member missing or dead injured or physically harmed self or household evacuated quickly with no time to prepare friend missing or dead life was threatened self or household prolonged separation from family pet missing or dead witnessed death injury self or household displaced from home 1 week or more home
34. W ES MEMO ac A a o A daa ida Dd thud 9 WA are inputs ai A a eat 10 What are activities ii Ads its 10 What are QUID ui a Aia 10 What areOULCOMES ii idad ceba 11 Aaa Evaluation for CCP siii alia A 11 Whatare the goals iio te ic 11 Whatis prograM FCC cateo 11 Whats program quality oir a ci 11 What is program consistenGy sich asta ati ian ed ind ante eesti 11 AAG Data Collection with the CCP Data Forms ccccccccccsccssccssecsseseeseseceesesssussseessasseaesseesersssseesas 11 Whatare the sources Of data iii iia 11 What are the CCP data collection forms 0 00 eee ee ee ein rorr rra rra rra rana 12 AAG Basic Forms REQUIRED Encounter Logs and Tallies oooocconcnioconococonoconononc rancio ro noroncrn nono 13 Whats thelr purpurina dt ica 13 Individual Crisis Counseling Services Encounter LOG oomcccccnnnnninicinicnnann can cnnn nono nono ncnanc rana rann carr cran 13 Whatis individual Counseling sevrsirirara a ia 13 What is in the Individual Encounter Log ooicnnninnconccnnonnnconnnarnnarn nara nrr nr rre 13 Whemis it TIE Unai rad ibas 14 How does the crisis counselor get the information for the Individual Encounter Log oionni n i 14 How are families or multiple persons treated oniinninnnninnnnnnnnnnoncnnaconacanarrarr rara 14 Group ENCOUNLER LOG mort A A A aE Nia 15 Whatare group encounters a cta 15 Whats in the Group Encounter Log tii iia 15 Brief Educational and Supportive Services Not Elsewhere Included W e
35. What language did you actually and primarily use to speak with this individual during the encounter This may be different than the preferred language If OTHER not English or Spanish fill in the other language SELECT ONLY ONE REFERRALS Based on your conversation with this individual you may have referred the individual for other services In the REFERRAL box select all of the types of services you referred the person to Please submit the completed form to the designated person in your agency who will review the form Thank you for taking the time to complete this form accurately and completely Public Burden Statement 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 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 20 minutes per encounter per year including the time for reviewin g 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 PROJECT OMB NO 0930 0270 Service Provider Feedback Survey Exp
36. about separation Be 2 a 0 1 2 3 4 17 Has your child been more quiet and withdrawn 4 r 0 1 2 3 4 18 Has your child talked repeatedly or asked questions about the disaster i i 0 1 2 3 4 19 Has your child s play been about the disaster F r 0 1 2 3 4 20 Have you noticed changes in your child s behavior or development e g bedwetting baby talk fighting or risk taking behavior or decline in school performance COUNT THE NUMBER OF ENTRIES IN THE 2 LAST COLUMNS ABOVE THAT HAVE A SCORE OF 3 OR 4 gt gt gt gt gt gt gt gt TOTAL IF TOTAL NUMBER IS 4 OR MORE DISCUSS THE POSSIBLITY OF A REFERRAL FOR SERVICES NUMBER FOR CHILDREN OVER THE AGE OF 10 OR IF YOU ARE CONCERNED ABOUT A YOUNGER CHILD YOU MAY ASK Have you had any thoughts or plans about either hurting or killing yourself NO YES IF YES refer for immediate psychiatric intervention IF NO continue to page 3 PLEASE ENTER REFERRAL INFORMATION ON PAGE 3 Child Youth Assessment amp Referral Tool page 3 REFERRAL select all that were communicated other crisis counseling program services e g group C counseling team leader follow up school counseling m mental health services e g professional longer term m community services e g FEMA loans housing employment counseling treatment behavioral or psychiatric services social services m substance abuse services e g professional b
37. accuracy when performing data entry on large numbers of forms with some commonality Participant Feedback Survey Participant Feedback Survey Project DR 1791 TX Employee Number EMP578 eek Administered 6 8 2009 Search for Participant Feedback Survey Submissions Or Enter new Participant Feedback Survey data Required Please identify below fields first This brief survey will help community leaders learn abou Required also help us to learn about how well crisis counselors an Name Hurrican Ike Texas Pride are meeting these n your help Do not put your name on this survey We al really feel If you filled out a survey like this in the past one Project H DR 1791 TX Employee H Instructions How would you rate the program or cd on the following areas In the boxes at right please X the box that best reprej the worst rating and 10 is the best rating Week Administered inm dd yvyy 6 8 2009 Best Worst How good was the information you got on how people information the best it could be 10 the worst it could between 2 9 CCC ICI CI Bw Ae User Manual Version 2 0 Page 8 of 15 SS SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual VALIDATION On some forms you will notice the asterisk symbol This symbol means that this is a required field In most cases you will sti
38. allow users to view and download the data in a variety of different formats The real time dynamic nature of this system will enhance the way grants are implemented and managed FORMS Intake Form The Intake Form is the starting point for the Federal Project Officer and the State Disaster Mental Health Coordinator and thus is a required form for the operation of the system User Manual Version 2 0 Page 3 of 15 SAMHSA DTAC X Online CCP Data Collection amp Evaluation System User Manual Required ISP Regular Services Program RSP Forms The following forms are required as part of both the ISP and the RSP reporting processes Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally Sheet Required RSP Forms These forms are required as part of only the RSP reporting process Adult Assessment and Referral Tool Child Youth Assessment and Referral Tool Optional RSP Forms The following forms are optional under the RSP Participant Feedback Survey Service Provider Feedback Survey data can be entered by only the external evaluation consultant REPORTS CCP Evaluation Online Database Report Reports for the following data sets can be generated either by using standard or custom methods Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally Adult Assessment and Referral Tool Child Youth Assessment and Referral Tool Participant Feedback
39. ample of counseling recipients Assessment and Referral Tools intensive service users multiple visits Individual Crisis Counseling Services Log Group Encounter Log Weekly Tally Sheet all services required Figure 2 CCP Data Collection Form Pyramid The CCP Toolkit includes standardized forms completed primarily by crisis counselors Advanced tools Regular Program Services RSP only Are used occasionally primarily administered by a senior crisis counselor or team lead e Are typically introduced by the RSP Include the Participant Survey the assessment and referral tools and the Provider Survey to be completed by crisis counselors and supervisors Basic tools RSP and Immediate Services Program ISP Are used often Are used as soon as possible after a disaster Are used as part of both RSP and ISP programs Include encounter logs for individuals and groups and Weekly Tally Sheets 12 Al SAMHSA DTAC Y Y Basic Forms REQUIRED Encounter Logs and Tallies What is their purpose Beginning as soon as feasible after the disaster and continuing through the ISP and RSP these forms are used to document all services delivered They are the basic and living record of the program and serve many purposes for both program monitoring and evaluation It is very important for services to be counted in a standardized way across all areas served by the program The forms are simple and take
40. ave any comments you would like to share If so please use the box below Public Burden Statement 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 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 20 minutes per participant per year 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 NA oerE OMB NO 0930 0270 Participant Feedback Survey Expiration Dae 01 31 2012 This brief survey will help community leaders learn about needs in our community It will also help us to learn about how well crisis counselors and outreach workers Project Name are meeting these needs We thank you very much for your help Do not put your name on this survey We want you to feel free to say how you really feel If you filled out a survey like this in the past week please do not fill in this one A pen is included for your use How would you rate the program or counselo
41. box that best describes your feeling or thought 4 notatall 2 a little bit 3 somewhat 4 quite a bit 5 very much How much have you been bothered by bad memories nightmares or reminders of what 1 2 3 4 5 happened l How much did you try NOT to think or talk about what happened or to do things that remind 1 2 3 4 5 you of what happened OH NL To what extent did you lose pleasure in things stay away from people or feel numb because 1 2 3 4 5 of what happened How much have you been bothered by poor sleep poor concentration feeling jumpy or angry 1 2 3 4 5 or being scared that something else bad will happen E Ti NE How down or depressed were you because of what happened 1 2 3 4 5 O How much were other stressful things harder to deal with because of what happened 1 2 3 4 rT OPeroe How much trouble did you have taking care of your health For example did you eat poorly 1 2 3 4 5 not get enough rest smoke more or drink more oh O How worried or upset are you about your reactions 1 2 3 4 rT OPeroe How much trouble did you have working or doing things like housework or schoolwork 1 2 4 5 rT PPorer How did your reactions keep you from getting along or having fun with family and friends 2 4 a n How much do you need help or more help from a counselor to deal with your reactions to the 1 2 3 4 5 disaster AAA Tm T If you answered many of these
42. c role These access levels are based on criteria such as tasks to be performed data oversight and evaluation program level oversight and accountability reporting requirements and system administration The chart below describes the types of users and their access levels Position Level Read Write Admin Reports Federal Project All grant data Intake Form Yes Yes Officer State Disaster Mental All grant data All grant data Yes Yes Health Coordinator State CCP Program Manager and State Data Evaluation Staff External Data External Evaluator External Evaluator No Yes Evaluation Staff Provider Survey only Provider Survey only Provider All their own provider data All their own provider data No Yes Please Note More staff levels than are listed in the chart above may be necessary for larger grants State Disaster Mental Health Coordinators should work with their Federal Project Officers to determine their needs and new access levels can be added 2 2 SYSTEM ORGANIZATION Two major components of the system are the forms and the reports The forms mimic the paper based data collection forms as closely as possible Data entries are stored in a back end database which means that the various system users can immediately access these data for such things as searching quality control and reporting The reports facilitate an accurate and user friendly view of the data in real time and
43. ch interface for each form the State Disaster Mental 12 Health Coordinator can pull up search results in a data grid which includes a checkbox to delete individual records or the entire set bute Ta delete any submission select it and click on Oelete Sutton Provider by Gulf Coast 001 Ilona Wolfe Center Gulf Coast 001 Ilona Wolfe Center Accomack Gulf Coast 001 ilona wolfe Center Accomack Please Note The Delete function is NOT REVERSIBLE User Manual Version 2 0 Page 12 of 15 gt SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual SEARCH FOR FORMS All tem rs have th ility t Sysiem a nave 1e ab y to Individual Crisis Counseling Services Encounter Log Search search for forms that have been Page previously submitted Each form will have a unique set of search criteria that will pull up results in a data grid These records can be viewed edited or deleted by the State Disaster Mental Project e El DR TEST VA z Health Coordinator or State data p lt evaluation staff only Users can ee oss navigate through the record set by SSSA either clicking on a particular ID number ran ad vyv E in the data grid or using the Next County Code of Record and Previous Record buttons ce from within the form pages themselves sult u sre artal value will improve the A search using these parameters will yield t
44. ch of these reports in a CSV file for use with Excel or any other spreadsheet or database application You can also download a text file with data that you can easily incorporate into the SPSS application by choosing Download SPSS User Manual Version 2 0 Page 14 of 15 gt SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual JAA Section 4 RESOURCES 4 1 OFFICE OF MANAGEMENT AND BUDGET OMB CLEARED CCP FORMS The most current version of all paper CCP data collection forms and accompanying instructions are available for download in PDF format from this section of the system The forms are available in English with Spanish translations Please Note You can complete these current PDF forms electronically and save them using the Adobe Reader application version 8 or later This is a free application which can be downloaded from http get adobe com reader otherversions 4 2 TRAINING MATERIALS These training materials will be available online 24 7 for all system users As enhancements are made to this system updates to these materials will be posted to this area with an appropriate version number 4 3 DATA DICTIONARY Under the Resources section you will find the data dictionary that is associated with the system s SQL database If you are using scanner technology to scan and capture form data you will need to use this set of defined fields in the setup of your scanner software s
45. code of service and zip code of service delivery Below this basic information section the form is similar to the Individual Encounter Log which also includes places to record encounter risk and demographic information Page 2 The second page of the form instructs the crisis counselor to read an introductory statement These questions are about the reactions you have experienced IN THE PAST MONTH By reactions mean feelings or emotions or thoughts about the events For each question choose one of the following responses from this card The response card is available in this toolkit and the CCP Application Toolkit and shows the respondent the choices for answering the statements Responses for the Adult Assessment and Referral Tool are as follows 1 Notatall 2 A little bit 3 Somewhat 4 Quite a bit and 5 Very much The crisis counselor indicates the respondent s answer and concludes with a score of the total number of responses that were indicated with a4or5 Referral Component If the respondent answers YES to item 12 Is there a possibility that you might hurt or kill yourself the crisis counselor should immediately refer the person for professional psychiatric or mental health intervention The CCP should have protocols or procedures in place for how a crisis counselor should respond or react if such an event occurs Many CCPs have team leaders or other staff with a mental health background to administer this
46. d with local program management only if the number of workers is greater than 20 Smaller programs receive less specific results When results are shared they are shown only in aggregations large enough to ensure that individual crisis counselors or small groups of counselors are not identifiable Participant Feedback Survey What is the Participant Feedback Survey This two page questionnaire seeks feedback and other information from service recipients The questions about services relate directly to the goals of crisis counseling such as reassurance and being helped to find ways to cope The first page concludes with a section on the ways in which the respondent was exposed to 22 Al SAMHSA DTAC the disaster The back of the survey collects information on event reactions such as posttraumatic stress depression impaired functioning and perceived need for additional help This is the Sprint E described earlier as part of the Adult Assessment and Referral Tool A brief statement to respondents informs them that ifthey answered many questions with high scores they might benefit from talking with a crisis counselor about their reactions A local phone number should be included on the form for this purpose The survey concludes with basic demographics Why is this necessary The survey plays three important functions for the CCP Firstthe survey provides information about service quality from the viewpoint of the recipient Because it
47. docs 24 How are the forms TOG IN ua A A eel ao bos 24 Where do completed tools g0 e eect teeter ieee ene eee eee eerste rra 25 How often are they SUDMINEO inicia td 25 What do Supervisors dO arssinat aa ainai eiaa 25 What happens NeXt nuit aa a a re hind ane annie 25 WOT How are the data entered viii E ata 25 What reports are EQUIP a 25 Whois responsible Tor Mis Work Picnic a dao 25 What resources are needed inci wav a ridin Geant 26 How are the data analyzed iii tara ada 26 Is this evaluation enumera ienirahe avenieiets 26 A A A Component II CCP Data Collection Forms Instructions and Survey Templates AAT Component Ill Crisis Counseling Assistance and Training Program CCP Online Data Collection and Evaluation System User Manual Version 2 0 gt SAMHSA DTAC gt SAMHSA DTAC y y y Component I Manual for the Use of CCP Data Collection Forms and Evaluation Al SAMHSA DTAC AA A Introduction the Basics What is the CCP The Crisis Counseling Assistance and Training Program commonly referred to as the Crisis Counseling Program or CCP is funded by the Federal Emergency Management Agency FEMA through the Robert T Stafford Disaster Relief and Emergency Assistance Act Public Law 93 288 as amended by Public Law 100 707 U S States Territories and federally recognized Tribes are eligible to apply fora CCP grant The CCP requires a Presidential declaration of disaster for Individual Assistanc
48. doing How are families or multiple persons treated Sometimes individual crisis counseling involves more than one person Perhaps the crisis counselor has spoken to a married couple a family or even a couple of friends This raises the issue of who received the counseling encounter The service recipient is defined as any person who actively participated in the session e g by verbally participating not someone who is merely present There may be two or more individuals helped at the same time One Individual Encounter Log form is completed for each individual actively counseled F or persons considered to be part of a family present for the encounter the Family Visit type is checked 14 SAMHSA DTAC Group Encounter Log What are group encounters Group encounters are very important and appropriate for disaster survivors because of their shared experiences The two types of group encounters are group crisis counseling and public education and the differences between them are subtle In group crisis counseling service recipients do most of the talking in public education the crisis counselor does most of the talking For example the crisis counselor may have made a presentation about common reactions to disaster The Group Encounter Log is not to be used to document visits with family members Please see above for instructions on Family Visit types What s in the Group Encounter Log Because of overlap in the type of inf
49. e and is administered through a F ederal interagency partnership between FEMA and the Substance Abuse and Mental Health Services Administration SAMHSA Center for Mental Health Services CMHS The CCP is composed of two grant programs 1 Immediate Services Program ISP that is 60 days in duration 2 Regular Services Program RSP that is up to 9 months in duration CCPs aim to meet short term behavioral health needs of affected communities through counseling outreach public education training and referral In recent years there have been approximately 15 20 active CCPs per year but in some years such as after the 2005 Hurricanes Katrina Wilma and Rita there have been more The CCP has provided brief behavioral health services to millions of disaster survivors since its inception and has become an important model for response to a variety of catastrophic events What are the roles of FEMA SAMHSA and SAMHSA DTAC The CCP is a partnership between FEMA and SAMHSA CMHS CMHS provides States and Territories with consultation and assistance in implementing the program The SAMHSA Disaster Technical Assistance Center DTAC provides technical assistance throughout the phases of disaster recovery including dedicated technical assistance for CCPs SAMHSA DTAC houses a library of print and electronic resource materials and maintains a toll free helpline 1 800 308 3515 a comprehensive website and an email address DTAC samsha hhs gov Wha
50. e care of yourself like eating 1 2 3 4 5 6 7 8 9 10 right and getting enough sleep How good of a job did the counselor or outreach worker do helping you to stay active in things like hobbies sports church 1 2 3 4 5 6 7 8 9 10 or volunteer work E a E How good of an idea is it to tell a friend who was upset by the 1 2 3 4 5 6 7 8 9 10 disaster to see this counselor or outreach worker Tr E 4 People are exposed to disaster in many different ways Please select all that apply to you by putting an X in the box family member missing or dead life was threatened self or household friend missing or dead witnessed death injury self or household pet missing or dead assisted with rescue recovery self or household home damaged or destroyed disaster unemployed self or household car or other vehicle or major property loss evacuated quickly with no time to prepare other financial loss prolonged separation from family Aa EP el al ee TOOoOUU injured or physically harmed self or household displaced from home 1 week or more PLEASE ALSO ANSWER QUESTIONS ON THE BACK These questions are aboutthe reactions you have experienced IN THE PAST MONTH By reactions we mean feelings emotions or thoughts about the disaster Your answers to these questions will help us to learn more about how people in our community were affected by the disaster For each question put an X in the
51. e from the Sprint E and are used with permission See the Evaluation Manual for documentation of reliability and validity REFERRALS In the REFERRAL box select all of the types of services you referred the person to If the service is not listed please provide the type of service next to OTHER SERVICES Please submit the completed form to the designated person in your agency who will review the form Thank you for taking the time to complete this form accurately and completely Public Burden Statement 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 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 20 minutes per encounter per year 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 PROJECTE Child Youth Assessment amp Referral Tool o Expiration Date 01 31 2012 Please use this tool as an interview guide 1 with children who have received individual cri
52. ehavioral or medical treatment or self help groups Was the referral accepted by the child Yes No Was the referral accepted by the parent caregiver Yes No RESPONSE CARD COUNSELOR COPY GIVE THE LARGER VERSION TO CHILD PARENT BEFORE ASSESSMENT Think about your thoughts feelings and behavior DURING THE PAST MONTH Use these frequency rating options to help answer how often the problem has happened in the past month For each question choose ONE of the following responses 0 1 2 3 4 S M T wiTth F s s m T w th F s S M T w Th F Ss s m T w th F s s m T w th F s xf x x xi ix Ix x x x x x X x x x x X x x X x E xX X xX X x x x x x x x x x x x xix x Not at all means A little bit means about Somewhat means about Quite a bit means Very much means never in the past month 2 times per month 1 2 times each week during 2 3 times a week during Almost every day the past month the past month INSTRUCTIONS PROJECT FEMA disaster declaration number Example DR XXXX State PROVIDER NAME The name of the program agency PROVIDER The unique number your program agency is providing services under EMPLOYEE YOUR employee number DATE OF SERVICE The date of the encounter in the format MM DD YYYY e g 01 01 2008 COUNTY CODE OF SERVICE
53. ekly Tally Sheet 16 What is the purpose of the Weekly Tally Sheet c ininnininninnnnononicnninnnonncnanc nan nran oran rnn nora rra 16 What goes in the county field vincia da 16 gt SAMHSA DTAC How ls the week designated vetada 16 How are hotline calllS counted mitra denen itn Anna 16 AAG Advanced Forms OPTIONAL Assessments and SUIVOYS ccccccccoconononcnonononononononcnonnnnonoronoranonnns 16 Whatis their PUmpOS vista id a AA ae 16 Why were assessment and referral tools Created cece eeee teeter tee te teeter ee EEEE EEEE 16 When and for whom are the assessment and referral tools used eee cette teeter etree rana nnono 17 Adult Assessment and Referral TOOL onnnniinnnnniinniconncnconncecrrrcrrrrrrr EAEAN NENEA REE EE EEn 17 Whats in the Adult Assessment and Referral Tool ionnninnnnnnnnininnninnininccnnni nana nana ran ran rra rra 17 How are adult Symptoms assessed oo eect ete et etree eee reir 18 IS The measure GOO maria a inant 18 How is the Adult Assessment and Referral Tool scored cnninconnnoncininonononinininananncnnnarir narrar rr 18 Is the Individual Encounter Log used t00 oo ee eececeeeseesee etree eae eeae seas i iaaa 18 References Adult Assessment and Referral TOI ooonnnnnncaninaninicanonana no noncnn nn nanano no nono nano na nano nana 19 Child Y outh Assessment and Referral TOOl iconninnnnninnconccnnncnncnaranaranccannrcncr rara rn rr rre 19 Whats in the Child Y outh Asse
54. equally important the skills and expertise of program staff the relationships between staff and local community leaders and the delineation of responsibilities among the different agencies involved Lack of one or more of these needed contributions can greatly limit an organization s ability to deliver services What are activities Activities are the means used to bring about program objectives Different CCPs aim for different mixes of public education and crisis counseling services according to what program leaders believe is best for their particular community Advanced training helps crisis counselors do their jobs more effectively especially when the disaster is especially severe or complicated CCP s vary in their attention to diversity in the population and in the emphasis they place on identifying and referring individuals with more severe mental health or substance abuse needs What are outputs Outputs are the measurable units of product from a program s activities Evaluations often focus on the outputs of the service delivery process such as the number of individuals who received crisis counseling and number of educational presentations made In some cases evaluations conclude with outputs which are used as a proxy for outcomes In other cases outcomes need to be measured directly in order to assess whether services are truly having an impact 10 Al SAMHSA DTAC What are outcomes Outcomes are the societal benefits
55. er for this project is 0930 0270 Public reporting burden for this collection of information is estimated to average 5 minutes per weekly tally sheet 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 When to Use This Form 1 This sheet is intended to capture all of the contacts you have had for a particular week AND they have not been captured on any other form a In other words if you have completed an Individual 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 them here NUMBER OF CONTACTS OR NUMBER DISTRIBUTED For each day of the week fill in the total number of contacts for each of the following types IN PERSON BRIEF EDUCATIONAL OR SUPPORTIVE CONTACT This is 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 TELEPHONE CONTACT This is the number of brief telephone contacts with individuals that did not result in in depth discussion
56. erview guide 1 with adults who have received individual crisis counseling on two or more occasions before this visit OR 2 with any adult at any time if you suspect the adult may be experiencing serious reactions to the disaster Do not use this form with children use the Child Assessment amp Referral Tool PROJECT FEMA disaster declaration number Example DR XXXX State PROVIDER NAME The name of the program agency PROVIDER The unique number your program agency is providing services under EMPLOYEE YOUR employee number DATE OF SERVICE The date of the encounter in the format MM DD YYYY e g 01 01 2008 COUNTY CODE OF SERVICE The 3 digit FIPS code for the county where the service occurred ZIP CODE OF SERVICE The zip code of the location where the service occurred LOCATION OF SERVICE Where did you provide the service SELECT ONLY ONE VISIT NUMBER Based on your conversation with the individual is this the 1 274 37 4h 5th or more visit for this person to your program All visits did not have to be with you SELECT ONLY ONE DURATION How long did your encounter last SELECT ONLY ONE If the encounter was lt 15 minutes record it on the Weekly Tally RISK CATEGORIES These are factors that an individual may have experienced or may have present in their life that could increase their need for services MORE THAN ONE CATEGORY MAY APPLY SELECT ALL CATEGORIES THAT APPLY The Adult Assessment and Referral Tool is a
57. es definitions and data collection These tools were originally evaluated and approved by the Office of Management and Budget OMB in September 2005 with an expiration date of September 2008 A revised set of tools was again submitted to OMB and was approved OMB No 0930 0270 in J anuary 2009 with an expiration date of J anuary 2012 Al SAMHSA DTAC What are some of the key changes between the 2005 and 2009 OMB approved forms The revised CCP standard data collection toolkit contains the six previous forms Individual Encounter Log Group Encounter Log Weekly Tally Sheet Adult Assessment and Referral Tool Participant Feedback Survey and Service Provider Feedback Survey as well as one new form the Child Y outh Assessment and Referral Tool The revised forms clarified definitions and added response options that occurred frequently within the other category in the previous forms As part of the revision to the Individual Encounter Log a section on event reactions was added These items measure the participant s behavioral emotional physical and cognitive reactions to disaster Responses to the event reactions section can be used to inform decisions regarding whether additional or more intensive services are needed for the individual or program How is the Evaluating and Monitoring the Reach Quality and Consistency of Crisis Counseling Assistance and Training Programs Toolkit Version 2 0 organized The Evaluating and Monitori
58. es can be included in the results survey link here Once again thank you for your participation as well as for the important work you do for name of Project Sincerely Date Dear friend Name of or reference to disaster caused many challenges and problems for many people Our crisis counseling project tries to help people cope with the stress of recovery To do our jobs well we need to know more about how people are doing now and if our crisis counselors are finding the best ways to be helpful Inside this packet is a very brief survey It will take you only a few minutes to fill out but will be very helpful to us Your answers will help us to help others The packet has a pen in it for you to use and keep It also has a stamped envelope for you to mail in your survey after you are done The survey does not ask for your name and is completely anonymous No one will know which survey you filled in Your answers will be used together with the answers of other people who are also kind enough to help us this week Please send your survey in by Date Of course it is fine if you choose not to participate Also you should feel free to leave any question blank that you don t want to answer Your opinions are important to us Thank you for taking the time to complete this survey Sincerely Name of Project Director Name of Project The Participant Feedback Survey Guidelines for Trainers The fo
59. ete Message El Attachment doc or pdf or xls H CCPdatabases LOREM IPSUM_pdf Browse Send E mails in Once they have read a message they may delete it from their message center Please Note While the system will allow for the upload of large files depending on the recipient s connection speed it may be best to limit file size to no more than 1 megabyte User Manual Version 2 0 Page 7 of 15 SAMHSA DTAC lt i Online CCP Data Collection amp Evaluation System User Manual REDUNDANT FIELD AUTO POPULATION A typical data entry worker will enter the same data repeatedly for one type of form To alleviate some of the repetitive field entries the system was designed to capture certain common data elements base data for each form and then auto populate that data into subsequent forms of the same type For instance on the Individual Crisis Counseling Services Encounter Log users will enter data for the following fields project number provider name provider number employee number date of service county code of service and zip code of service Once these fields are entered they will be auto populated into every subsequent Individual Encounter Log form that the user initiates during that login session The user can opt to change data used to auto populate the fields as needed for instance when the date of service or any other field changes This feature is beneficial to speed and
60. ferent sources Data about event characteristics are found in the project s grant application Data about community characteristics are derived from the census Standard statistics for ethnicity race age distribution and percentage of people living in poverty can be recorded for each county Data about activities 11 SAMHSA DTAC such as types of staff training can be collected from program leaders The remaining data on activities and outputs are collected throughout the program period by crisis counselors using the CCP toolkit What are the CCP data collection forms The CCP data collection forms are a set of standardized forms that are completed by crisis counselors Because the data are collected in a consistent way from all programs they can be merged into an ongoing national database that provides CMHS with a way of producing summary reports of services provided across all projects funded The structure of the toolkit might be described as a pyramid involving tools that are used with decreasing frequency as one moves up from the base of the pyramid to the top The basic tools include encounter logs for individuals and groups and weekly tallies The advanced tools are participant surveys assessment and referral tools and provider surveys CCP Data Toolkit Pyramid C Advanced Tools El Basic Tools Provider Survey optional crisis counselors and supervisors Participant Feedback Survey optional time based s
61. ferral options for the child youth and or family This includes being prepared to offer youth and parents the name of an organization that has agreed to accept CCP referrals and a contact at that organization If the total number is three or less the counselor can still recommend a referral if the child youth is in need of specific support or intervention or may recommend another visit with the current counselor Is the Individual Encounter Log used too Yes the crisis counselor should also complete the Individual Crisis Counseling Services Encounter Log as usual Some of the information is duplicated but the Individual Crisis Counseling Services Encounter Log and the Child Y outh Assessment and Referral Tool are used for different purposes making it difficult to count these services solely from the Adult Assessment and Referral Tool References Child Youth Assessment and Referral Tool Cohen J A Kelleher K J amp Mannarino 2008 Identifying treating and referring traumatized children The role of pediatric providers Archives of Pediatrics and Adolescent Medicine 162 447 452 Kronenberg M E Hansel T Brennan A M Osofsky H J Osofsky J D Lawrason B 2010 Children of Katrina Lessons learned about postdisaster symptoms and recovery patterns Child Development 81 1241 1259 Riise K S Hansel T C Steinberg A M Landis R W Gilkey S Brymer M J etal 2009 The Louisiana Specialized Cri
62. ficers for the CCP grant as part of routine and ongoing progress calls and quarterly final reports Y Y Y Advanced Forms OPTIONAL Assessments and Surveys What is their purpose Although there may be exceptions the advanced tools are typically introduced when the RSP begins The Adult and Child Y outh Assessment and Referral Tools and the Participant Feedback Survey collect more in depth information about service recipients than is captured by the encounter logs and tallies The Service Provider Feedback Survey measures the opinions experiences and perceived stress of crisis counselors and their supervisors Use of the advanced tools during the RSP is strongly encouraged but not required Why were assessment and referral tools created Crisis counseling programs focus on short term behavioral health interventions but some people need either longer or more intensive interventions Sometimes more intensive interventions are offered in collaboration with CCPs but more often crisis counselors need to rely on other community and State programs Previous research suggested that making referrals to more intensive mental health and substance abuse services was a problem area for many CCP providers The issues spanned a range from limited availability of services 16 SAMHSA DTAC which of course cannot be addressed by means of a tool to uncertainty about when to make referrals This tool was created to help crisis counselors make these
63. h no or minimal interaction Material mailed to people s homes and or left at a person s home Material left in public places Community networking and coalition building Note If the number is zero the field may be left blank Reviewer Name Signature Date of Review Public Burden Statement 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 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 5 minutes per weekly tally sheet 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 INSTRUCTIONS WEEKLY TALLY SHEET BRIEF EDUCATIONAL AND SUPPORTIVE SERVICES NOT ELSEWHERE INCLUDED Public Burden Statement 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 OMB control number The OMB control numb
64. hat goes in the county field This should be the last 3 digits of the FIPS code for the county or parish A counselor working in multiple counties or parishes should do one Weekly Tally Sheet for each county How is the week designated This should always be Sunday s date For example a part time crisis counselor working on Friday and Saturday should use the previous Sunday s date How are hotline calls counted Disaster related hotline contacts may be counted as CCP services if a the services have been paid for by the grant and b the hotline contractor has been issued a provider number If the State U S Territory or federally recognized Tribe has hired a specific staff member to answer hotline calls for the CCP then an employee number will be issued There must be a system in place for assessing and documenting which hotline calls are related to disaster survivors If hotline calls are recorded on the W eekly Tally Sheet they are indicated as telephone contacts These calls are less than 15 minutes in duration When the hotline contact otherwise meets the definition of individual crisis counseling and the contractor has provided a clear protocol for monitoring the scope and duration of calls the Individual Encounter Log may be used On the Individual Encounter Log itself show the location as phone counseling These calls are 15 minutes or longer in duration This protocol must be documented and provided to the Federal Project Of
65. he results below ty number or county nome Zip Code of Service oO Search Collection Reset Search Below a the ltt wth above cearch certera To viem update informetron on the tool please cick on the Record 2 To ven informetvon on a disaster please click on the Disaster Number 2 Matching Record Delete Bacer Type Disaster Provider Tool County EAS r y 159 De TES Spindietep MMMA 001 Ilona Accomnack wote Harris County MAMA 3 3 GENERATING REPORTS Powerful tools have been incorporated into this system to allow users to better analyze track and report on the various activities occurring under each grant and in some instances over a series of grants Reports are provided in a variety of formats which makes incorporating the data into other documents very simple Federal users will be able to access reports across States and across disasters State level users will only be able to access reports related to their particular State CCP EVALUATION ONLINE DATABASE REPORT Reports are available for data from the following forms the Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally the Participant Feedback Survey and the Service Provider Feedback Survey An external data evaluation consultant is the only user who can generate the Provider Survey Report You can generate reports using predetermined reporting criteria standard reports or cust
66. he person needs or asks for help completing the survey Some people may not be able to read at the level required fifth to sixth grade or for some other reason language visual impairment may need help to complete the survey Unfortunately you cannot help them If someone asks you for help you might tell them that you would really like to help but you ve been told not to because the people doing the survey need to be sure that counselors haven t influenced the results Please use this as an occasion to help the participant think about other sources of potential help Is there a family member who could read them the questions A friend When you think people might need help even if they didn t ask you might tell them that many people prefer to have a family member or friend read them the questions so that they can think only about the answers What should you do if the person implies that they shouldn t be the one to complete a survey Sometimes people think they aren t the right people to participate Tell them that their participation will be extremely helpful no matter what their answers might be If someone says he d like to but he s really busy emphasize how little time the survey will take However don t push too hard People have the right to refuse and we all need to respect that Should you do the encounter logs as usual Yes please complete the Individual or Group Encounter Log as you would normally We are counting on you
67. he person the packet We don t want the survey to interfere with your work Please try to behave as you would normally Introduce the survey when your conversation is starting to wind down Please don t give it any earlier if it would harm your encounter And please don t wait until the person is rushing off to the next thing he or she needs to do This requires great judgment which we are confident you have After all knowing when to continue and when to stop is a key skill of crisis counselors What should you say when giving someone the packet Use your own words but you can basically say the same thing that the cover letter says 1 that name of project is trying to help people cope with the stress of the disaster and recovery 2 that to do your jobs well it is helpful to learn more about how people are doing now and about whether crisis counselors are finding the best ways to be helpful and 3 that this packet has a very brief survey that will take them only a few minutes to fill out but will be very helpful to the project Appeal to their altruism Their answers will in fact help the project to do a better job of helping others Please be assured that the survey is not a burden It really is short and researchers have repeatedly found that people who have been through serious events understand why it is useful to ask them about it and the services your program is providing to support them in coping with the event You can also point
68. he types of need present in the community TT a 1 TI E The overall quality of services being provided by the project a 2 A 2 E u e 19 How likely you would be to recommend name of project to a 1 2 3 4 5 6 7 8 9 10 friend or family member if he or she had the need i l jA i E B E r y PLEASE ALSO ANSWER QUESTIONS ON THE BACK These next questions are about the reactions you have experienced IN THE PAST MONTH By reactions we mean feelings emotions or thoughts about the crisis counseling program work you are doing Your answers to these questions will help us to learn more about how service providers were themselves affected by the disaster and the work For each question put an X in the box that best describes your reaction 4 notatall 2 a little bit 3 somewhat 4 quite abit 5 very much Has your ability to handle other stressful events or situations been harmed by your crisis counseling work or your reactions to it Has the crisis counseling work or your reactions to it interfered with how well you take care of your physical health For example are you eating poorly not getting enough rest smoking more or finding that you have increased your use of alcohol or other substances No Ww A al How much has the crisis counseling work or your reactions to it interfered with your ability to work or carry out your other daily activities such as housework or schoolwork
69. hen out in the field working with disaster survivors Secondly data management staff can use it to provide instruction on form data entry via the CCP data website and key functions of the website data downloads analysis and progress reporting Lastly but importantly it can be used as an ongoing reference when questions arise regarding all facets of CCP data collection and evaluation AA J Understanding Program Evaluation Whatis program evaluation Program evaluation refers to systematic efforts to collect analyze and interpret information about the delivery or outcomes of interventions Program monitoring typically relies on easily measurable indicators that can be tracked over time such as the number of crisis counseling encounters or client satisfaction Why is it important The continuing recognition acceptance and support of the CCP depends at least in part on its ability to show sponsors and other interested parties that it delivers the services it intends to deliver and that survivors benefit from the services provided Program achievements are documented through program evaluation A useful management tool evaluation helps program administrators to determine if the project is proceeding according to plan so that they can make midcourse corrections when needed SAMHSA DTAC AS How are results used Ultimately evaluation is not about gathering data but about using data to draw conclusions Evaluation resu
70. ices Encourter Leg Race For each question read the options and ack the 3 dividual to select the option or opticas that best M American Indian Alaska Native I Native Haw probe in or tre sean vid ist ne M Asian I white G SELECT ONLY ONE T Black or African American 3 SELECT ONLY ONE SELECT ALL THAT APPLY Ethnicity ETHNICITY SELECT ONLY ONE Hi i i O i ic Hispanic or Latino Not Hispanic g PRIMARY Wher language did you actually and primarily use to LANGUAGE OF speak weh this individus during the encourter This A CONTACT moy be differant than the preferred language I Primary Language of Contact OTHER met English or Spamsh fill ir the other language SELECT ONLY ONE e English Spanish nr If Other please specify DATE FIELDS All fields within the system that require the entry of a calendar date utilize a calendar entry method This method automatically inserts the correct day month and year formatting which is important to data consistency _ cies Start Date E 14 2009 End Date Estimate the number of people to be served through pri View Input Update Targets June 2009 gt Su Mo Tu We Th 123 4 8 9 10 11 15 16 17 18 22 23 24 User Manual Version 2 0 Page 6 of 15 SAMHSA DTAC lt i Online CCP Data Collection amp Evaluation System User Manual SYSTEM MESSAGE CENTER Federal staff can send out simple text
71. ilable at http www esi bethesda com CCPE valuation You will need a user login and password to access the system Federal staff members have logins already established in the system Once a State decides to apply for an Immediate Services Program ISP the State Disaster Mental Health Coordinator login will be activated and provided by a DTAC staff member It is the responsibility of the State Disaster Mental Health Coordinator to work with DTAC to set up login accounts for his or her staff providers and provider employees and to assign them to a disaster If you do not have a login or have forgotten your login please contact the SAMHSA Disaster Technical Assistance Center DTAC team contact information is in Section 1 2 System Support 1 2 SYSTEM SUPPORT Please feel free to contact the SAMHSA DTAC team DTAC samhsa hhs gov or 1 800 308 3515 for support or technical assistance on any issues you may encounter while using this system Hours of operation Monday Friday 8 30 a m through 5 30 p m eastern time User Manual Version 2 0 Page 2 of 15 Sl SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual AAT Section 2 SYSTEM OVERVIEW 2 1 USER ACCESS LEVELS The system is set up to accommodate different types of users each with a different role within the CCP evaluation process Based on their login information users will see only the sections of the system that relate to them and their specifi
72. information about the delivery of services Program evaluation typically relies on easily measurable indicators that can be tracked over time such as the number of crisis counseling encounters or participant satisfaction The continuing acceptance and support of the CCP depend at least in part on its ability to show sponsors and other stakeholders that it delivers the services it intends to deliver and that disaster survivors benefit from the services provided Program achievements are documented through program evaluation A useful management tool evaluation helps program administrators to determine if a CCP is proceeding according to plan so they can make midcourse corrections when needed For example program evaluation can reveal trends in the demographics of individuals who receive CCP services allowing for an assessment of whether the program is reaching target at risk populations Program management can then help staff identify needed adjustments to outreach strategies Ultimately evaluation is not about collecting data but about using data to draw conclusions Evaluations are useful only if their results are communicated Program managers should regularly share evaluation results in staff meetings quarterly updates or via visual aids such as charts and graphs This feedback can then facilitate discussion with program staff on means to improve services 1 1 SYSTEM ACCESS AND LOGIN The CCP Online Data Collection and Evaluation System is ava
73. ings NO YES tT 2 3 4 5 6 7 8 9 10 offered by the State or your agency E El E E The next questions have to do with other things that can influence your work such as supervision and support Again please X the box that best represents your opinion on a scale where 4 is the worst or feast you can imagine and 10 is the best or most you can imagine How would you rate name of project on these other areas WORST BEST Quality of the supervision provided to you 1 2 2 e E 2 y E i Opportunities to interact with other staff in supportive ways 1 2 3 Es E u K 19 Support amp training provided to help you avoid compassion fatigue 1 2 3 4 5 6 7 8 9 10 or to cope with the stress of listening to and helping others E Opportunities for professional and personal growth 2 E 2 e E E K ll Appropriateness of the workload i e neither too much nor too little i E 3 A E 6 e E E ble Adequacy of the resources and tools you had available to do your job 1 E 2 2 u E E w How well you understood how your job fit into the bigger picture of 1 2 3 4 5 6 7 8 9 10 your community s response to the disaster E E How well data from the evaluation were shared with crisis 1 2 3 4 5 6 7 8 9 10 counseling teams or used to inform their work How well you believe the types of services provided by the 1 2 3 4 5 6 7 8 9 10 project matched t
74. ions involve at least 2 or more unrelated participants excluding staff 3 Do not use this form for families Please see the instructions for the Individual Crisis Counseling Services Encounter Log GROUP CRISIS COUNSELING OR PUBLIC EDUCATION SELECT ONE THE DATA ON THIS LOG CANNOT BE ENTERED OR COUNTED UNLESS YOU INDICATE TYPE OF SERVICE Group Crisis Counseling refers to services that help group members understand their current situation and reactions to the disaster review or discuss their options provide emotional support or referral services and or provide skills to cope with their current situation and reactions In group counseling participants do most of the talking Public Education refers to services that provide general psycho educational information to survivors on disaster services available and key concepts of disaster mental health Common activities in this category include but are not limited to public speaking at community forums in service group meetings and local government meetings In public education the crisis counselor does most of the talking PROJECT FEMA disaster declaration number Example DR XXXX State PROVIDER NAME The name of the program agency PROVIDER The unique number your program agency is providing services under EMPLOYEE YOUR employee number DATE OF SERVICE The date of the encounter in the format MM DD YYYY e g 01 01 2008 COUNTY CODE OF SERVICE The 3 digit FIPS code fo
75. iration Date 01 31 2012 This brief survey is being conducted to learn about your opinions and experiences as an outreach worker crisis counselor team leader or supervisor Do not put your name on this survey We want you to feel completely free to express your opinion Please use the black pen that came with this survey THANK FOR YOUR PARTICIPATION The first set of questions is about Crisis Counseling Program CCP training First please indicate whether or not you have had each type of training Then for each training you have completed please rate how well the training helped to prepare you to do your job Please X the box that best represents your opinion on a scale where 4 is the worst or feast you can imagine and 10 is the best or most you can imagine Have you had IF YES How would you rate this training Type of training this training WORST BEST Po NO YES 1 2 3 4 5 6 7 8 9 10 CCP Core Training m C i Nm n T POP nn Transition to Regular Service Program NO YES 1 2 3 4 5 6 7 8 9 10 RSP Training OD E f o NO YES 1 2 3 4 5 6 7 8 9 10 RSP Mid program Training rer mM nn rl ts mT nn n NO YES 1 2 3 4 5 6 7 8 9 10 Disaster Anniversary Training OT NN NO YES 1 2 3 4 5 6 7 8 9 10 RSP Phasedown Training rer a m m m F Ei E m E nm Training on how to complete the CCP NO YES 1 2 3 4 5 6 7 8 9 10 evaluation tools e g logs weekly tally C l Other crisis counseling train
76. is may be different than the preferred language If OTHER not English or Spanish fill in the other language that the person spoke in SELECT ONLY ONE EVENT REACTIONS Do not use this as a checklist during the encounter Complete this based on your observations and conversation AFTER the service is complete SELECT ALL THAT APPLY If the person has no apparent problems check coping well REFERRALS Based on your conversation with this individual you may have referred the individual for other services In the REFERRAL box select all of the types of services you referred the person to If the service is not listed please provide the type of service next to OTHER SERVICES REVIEWER Team lead or direct supervisor to review completed form for accuracy and then sign and date date of review Please submit the completed form to the designated person in your agency who will review the form Thank you for taking the time to complete this form accurately and completely Public Burden Statement 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 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 4 minutes per encounter per year including the time for reviewing instructions searching existing data sources gathering and maintaining the da
77. ith SAMHSA DTAC Lori A McGee M A with SAMHSA DTAC Leisel Bucheit with SAMHSA DTAC Vick Chan with SAMHSA DTAC Ilona Wolfe with SAMSHA DTAC Mitch Q Wang Ph D with Expert Health Data Systems Inc Kazuaki Uekawa Ph D with SAMHSA DTAC A SAMHSA DTAC Table of Contents 4 4A A Component I Manual for the Use of CCP Data Collection Forms and Evaluation FA Y Introduction the BaSilS oooonocincnicnnonicononnconcnnnonnco nono nono ronrnn corran ron rr ar carro rra rro nn narran rar cnn 7 Whatis the GCP P sirs uiing aaan ara aE OaS aa Aaa ETENE adel ates 7 What are the roles of FEMA SAMHSA and SAMHSA DTAC concciicccccncnnncnnnonononnnennncnancnann nana canncninanas 7 What are the roles of States and or service providers funded with a CCP assesseer 7 Why is it important to collect consistent data on CCP services coccicciiccinoccnoncnonononcnancnana nana nana nana nana 7 What are some of the key changes between the 2005 and 2009 OMB approved forms sessen 8 How is the Evaluating and Monitoring the Reach Quality and Consistency of Crisis Counseling Assistance and Training Programs Toolkit Version 2 0 organized c onccnnincninninnccnncniccnanncnanonancnancnncnn 8 How should it be Usd tira A A A SATE 8 AAT Understanding Program Evaluation ccccccccsssssssscssessssscsescerssesescrescsessesssessessesssesssassersoatees 8 Whatis program evaluation vita is 8 WAY IS EMM POMANE rita ea 8 HOW are TeSUITSUSEO faint ender a did 9 HO
78. l Difficulty falling or staying asleep Difficulty concentrating On guard hypervigilant Despair hopeless Eating problems Difficulty remembering things Agitated jittery shaky Feelings of guilt shame Worsening of health problem Difficulty making decisions Violent or dangerous behavior Numb disconnected Fatigue exhaustion Preoccupied with death destruction Acts younger than age children or youth COPING WELL NONE OF THE ABOVE APPLY PLEASE CONTINUE ON PAGE 2 ON BACK Individual Crisis Counseling Services Encounter Log long version page 2 REFERRAL select all that were communicated E crisis counseling program services e g group counseling team leader follow up m mental health services e g professional longer term counseling Pn is treatment behavioral or psychiatric services other specify in box gt substance abuse services e g professional behavioral or Note what the referral was for not where it was made to medical treatment or self help groups such as AA or NA NO REFERRAL PROVIDED Reviewer Name Signature Date of Review INSTRUCTIONS INDIVIDUAL CRISIS COUNSELING SERVICES ENCOUNTER LOG When to Use This Form Complete this form immediately after the individual crisis counseling service is provided 1 Complete this form for each individual who receives individual crisis counseling services 2 An individual crisis counseling encounter is defined as
79. le I m doing fine you should give this to someone who really needs help Tell them that their participation will be extremely helpful no matter what their answers might be Whether their opinions are good or bad whether they feel good or bad their survey is just as important as anyone else s If someone says he d like to but he s really busy emphasize how little time the survey will take However don t push too hard People have the right to refuse and we all need to respect that Should you do the encounter logs as usual Yes please complete the Individual or Group Encounter Log as you would normally We are counting on you This survey will stand or fall on the crisis counselors Please approach it positively and be assured that it is not a burden to participants Many people will appreciate the opportunity to give back This is a healthy thing We hope we ve made this as little burden as possible for you As always we count on your expertise and your exceptional ability to engage people We can t wait to share the results with you which we are sure will help us to show how good a job we are all doing while also giving us some guidance about how to further improve For additional information on the Participant Feedback Survey please contact the Substance Abuse and Mental Health Services Administration SAMHSA or Federal Emergency Management Agency Project Officer for this grant or call the SAMHSA Disaster Technical Assistance Ce
80. ll be able to submit the form without these required fields filled in but please be aware that you should be making every effort to collect all required data In some areas of the system you may encounter a validation error message upon clicking the Submit button A validation error will occur if you have attempted to enter data that are outside the given constraints of particular fields or if you have neglected to enter any data in a field that is vital These validation errors show up in red text at the top of the page and will specifically indicate which fields were entered improperly The following errors occurred while attempting to submit information Please provide Project Please provide Provider Name Please provide County Please provide Date of Service Or Enter new Individual Crisis Counseling Services Encounter Log data Please identify below fields first Required Project H Select Select Provider Name H Provider H Employee H q Select Date of Service mm dd yyyy El County Code o Service Zip Code of Service H 5512 Continue Reset User Manual Version 2 0 Page 9 of 15 DEJO SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual 4A GT Section 3 USING THE SYSTEM 3 1 SETTING UP A DISASTERICCP PROFILE INTAKE FORM The sole data entry feature for Federal level s
81. llowing guidelines provide information on the Crisis Counseling Assistance and Training Program CCP Participant Feedback Survey and how it is administered This information is being provided to CCP trainers and program leadership as background information prior to instructing crisis counselors on the administration of the Participant Feedback Survey Training on the Participant Feedback Survey may be done during the Transition to Regular Services Program Midprogram Anniversary or Phasedown trainings What is the participant survey This two page questionnaire seeks feedback and other information from service recipients The questions about services relate directly to the goals of crisis counseling such as reassurance and being helped to find ways to cope The first page concludes with a section on the ways in which the respondent was exposed to the disaster The back of the survey collects information on event reactions and demographics How is the survey used The survey plays three important functions for the program First the survey provides information about service quality Because it is not feasible to measure client outcomes assessing client perceptions is the next best approach We might find that some of the ratings are more positive than others We ll be happy about the high scores but we can also learn where we can improve Second the survey provides the program with excellent information about the experiences and reactions of people
82. lts are open to interpretation A program may reach a large number of people but only a fraction of the total population at risk Program results may involve tradeoffs For example crisis counselors who tirelessly throw themselves into their work may realize greater consumer satisfaction but experience greater burnout An innovative program may serve fewer clients but get better results for those it does serve Different stakeholder groups may judge these exchanges differently Evaluations are useful only if their results are communicated Program managers should regularly share results in staff meetings quarterly updates or even graphs posted on the wall This feedback can then facilitate discussion on means to improve services For example noting that one outreach team dramatically increased its number of counseling encounters may encourage workers in the field to share an innovative outreach technique Or it might reveal that the team is counting very brief contacts as counseling which would allow the supervisor to give feedback to staff about ways to deepen their discussions with survivors It is critical that results are shared in a climate that is supportive and curious What might these data be telling us not rigid and punitive How does it work Program evaluation or program monitoring is much more likely to be useful and meaningful if it is grounded in an understanding of how a program operates what resources it has what it does
83. me of Project staff member Enclosed in this packet is a brief anonymous survey This survey will help us learn about your opinions and experiences with name of Project At this time we are giving this survey to crisis counselors outreach workers and team leaders who have been working with name of Project for one month or longer If you have not been working at the project for at least one month please turn this packet back in We will be doing this survey again in a few months and will seek your opinion at that time As direct service providers you experience firsthand the effectiveness of the program we have put into place We want your opinion about the training resources and opportunities for support provided to you on the job We also want to know how you view the quality of services the project provides We know that you as someone on the front lines understand the project through your direct experience which makes your feedback especially helpful and relevant In addition there is a portion of the survey that checks in with you about the stress this job can sometimes bring If you feel you need some additional support please call You will be taking this survey anonymously and therefore will not be asked for your name or any other identifying information In addition a stamped addressed return envelope is being provided in this package so you can mail the survey back yourself without any concern that someone in the program ma
84. messages with attachments to State Disaster Mental Health Coordinators on an individual or group basis This feature is useful for sending out notifications such as system maintenance or update notices alerts to new policies and any other project related information The sender simply identifies the recipients and enters a subject line and text for the body of the message The body field only allows for the entry of unformatted text bold underlining italics colors and the like are not supported but this field can contain an unlimited amount of characters There is also a file attachment option which will permit you to attach a single file of any file type to the message Message recipients will see any messages sent to them on their homepage after they log Send E mails For multiple selections use Ctrl click E mail to Select Name s from the list Federal PO Virginia Mellie Randall Virginia Welcome Ilona Wolfe Active Disasters Click on the Disaster Number below co access the Intake and erter the necessary state speafic data at the bottom of t I Check here to send E 1 Sonda Form for a particular disaster he form he Provider Name s op MAMA Subject Message Center Body You have 2 message s Helio and Welcome This message is to co working Attached are session Subsect Sincerely Your Federal Project Officer Del
85. n interview guide and you may ask the individual whether or not he or she has experienced the listed factors Note this instruction is not the same as for the Individual Crisis Counseling Services Encounter Log DEMOGRAPHIC INFORMATION For each variable SELECT ONLY ONE The Adult Assessment and Referral Tool is an interview guide and you may ask ask the individual these questions as needed Note this instruction is not the same as for the Individual Crisis Counseling Services Encounter Log For each question read the options and ask the individual to select the option or options that best describes him or her AGE SELECT ONLY ONE SEX SELECT ONLY ONE RACE SELECT ALL THAT APPLY ETHNICITY SELECT ONLY ONE PRIMARY LANGUAGE OF CONTACT What language did you actually and primarily use to speak with this individual during the encounter This may be different than the preferred language If OTHER not English or Spanish fill in the other language SELECT ONLY ONE ASSESSMENT QUESTIONS GIVE THE RESPONSE CARD TO THE INDIVIDUAL For each question put a check mark in the appropriate box based on the individual s responses At the end of the 11 questions COUNT the number of check marks in boxes 4 and 5 This is the person s score For example an individual who answered quite a bit on Questions 6 and 7 and very much on Question 11 and somewhat on Questions 1 5 and 8 10 would receive a score of 3 The assessment questions com
86. ng the Reach Quality and Consistency of Crisis Counseling Assistance and Training Programs Toolkit Version 2 0 is organized into three components 1 The first component is the Manual for the Use of CCP Data Collection Forms and Evaluation The manual is organized as a series of questions that outreach workers crisis counselors supervisors program planners and data managers might ask as they perform ongoing program monitoring The manual includes information on evaluation and use of the data collection forms 2 The second component consists of the CCP data collection forms and their instructions OMB 0930 0270 expiration 1 31 2012 Additional templates are also included for the administration of the Service Provider Feedback Survey and the Participant Feedback Survey 3 The third component consists of the Crisis Counseling Assistance and Training Program CCP Online Data Collection and Evaluation System User Manual Version 2 0 The user manual provides an overview of how to use the CCP Online Data Collection and Evaluation System including data entry via the CCP data website http www esi bethesda com CCPE valuation data results and reporting How should it be used The CCP data toolkit was created to serve three important functions First it should be used for training direct service Staff e g crisis counselors and or outreach workers and other relevant program staff about CCP evaluation data forms and their appropriate use w
87. nter at 1 800 308 3515 and ask to speak with the technical assistance specialist assigned to this grant Thank you for this and everything you do The Participant Feedback Survey Guidelines for Crisis Counselors The following guidelines provide information on the Crisis Counseling Assistance and Training Program CCP Participant Feedback Survey and how it is administered This information is being provided to CCP crisis counselors as background information to be reviewed prior to survey administration Training on the Participant Feedback Survey may be done during the Transition to Regular Services Program Midprogram Anniversary or Phasedown trainings What is the Participant Feedback Survey This brief survey provides information to program leadership about participants opinions about crisis counseling and their experiences in and reactions to the disaster The survey is NOT used to evaluate the work of individual counselors The data are examined only in large groupings defined by State region or participant characteristics To whom is the survey given During the selected survey week the questionnaire is to be given to ALL adults receiving in person individual or group crisis counseling These are generally the same people for whom you would complete an Individual Crisis Counseling Services Encounter Log or a Group Encounter Log for group crisis counseling The survey is NOT to be given to people who would be recorded as receiving a
88. o that data can be properly imported into this system Please contact the DTAC Team at DTACOsamhsa hhs gov or 1 800 308 3515 for technical assistance with using the data dictionary and with transmitting data to be uploaded to the system Please Note The data dictionary may change periodically when the database is updated You will be notified via the system s message center when updates are available User Manual Version 2 0 Page 15 of 15
89. omized reporting criteria custom reports You can run reports to appear on screen or generate and download them as Adobe Portable Document Format PDF files Microsoft Word documents or CSV files to use with Excel or any other spreadsheet or database application User Manual Version 2 0 Page 13 of 15 E SAMHSA DTAC Online CCP Data Collection amp Evaluation System User Manual STANDARD PROGRESS REPORT The Standard Progress Report contains data on disaster outreach services individual encounters by age and monthly trends for individual group encounters and risk factors You can run reports to appear on screen or generate and download them as Adobe PDF files Microsoft Word documents or CSV files to use with Excel or any other spreadsheet or database application Individual Encounter by Age Eo e e p ga a y o e o os j id SO TRAVERS 9 Liria or veh ae a A 0 Q Frequency preschool 9 5 adolescent 12 17 WA GE 001 Accomack E 0 75 Brunswick MA 035 Carroll ME 059 Farfor DR 1791 TX Hurrican Ike Texas Pride DR TEST VA VA Crisis Counseling Program e EAT gt e bare 9 aja a O AAA CCP EVALUATION ONLINE DATABASE DOWNLOAD Reports are available for data from the following forms Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally the Participant Feedback Survey and the Service Provider Feedback Survey You can download ea
90. omposed of a mixture of the previous list or had no clear group identity Part 4 Focus of the Group Session The fourth part asks the counselor to describe the purpose of the group as one or more of the following 1 education about reactions to disaster 2 education about community resources 3 mutual support 4 stress management or skills building 5 conflict resolution 6 community action 7 information about CCP and 8 other Reviewer Signature Block After crisis counselors have turned in their completed forms to the team leader the team leader is expected to review the forms for completeness and validity In the reviewer signature block the team leader prints and signs his or her name and writes the date to indicate when the form was reviewed 15 A SAMHSA DTAC Brief Educational and Supportive Services Not Elsewhere Included Weekly Tally Sheet What is the purpose of the Weekly Tally Sheet Crisis counselors engage in many activities that are not captured by the Individual Encounter Log or Group Encounter Log but they are nonetheless important For these other activities crisis counselors use the Brief Educational and Supportive Services Not Elsewhere Included W eekly Tally Sheet W eekly Tally Sheet for short This includes for example brief interactions phone calls or email exchanges distribution of materials and community networking and coalition building Daily tallies and weekly totals are recorded W
91. on and Policy in Mental Health and Mental Health Services Research 36 206 214 J ones K Allen M Norris F Miller C 2009 Piloting a new model of crisis counseling Specialized crisis counseling services in Mississippi after Hurricane Katrina Administration and Policy in Mental Health and Mental Health Services Research 36 195 205 Child Youth Assessment and Referral Tool What s in the Child Youth Assessment and Referral Tool Page 1 As with the other CCP forms the first part may be filled out prior to the visit including project number FEMA disaster response number DR XXXX State provider name provider number employee number date of service county code of service and zip code of service W hen the visit starts fill in the visitnumber and indicate whether a parent or caregiver is present during the visit Below the Encounter Information section there is a Risk Category section that allows you to check off how children adolescents or household members were affected by the disaster and its aftermath The last section on this page is a Demographic Information section to enter basic characteristics of the child being interviewed Page 2 The second page of the form instructs the crisis counselor to read an introductory statement I want to talk to you about your your child s feelings and thoughts about the disaster and how much they are causing problems now Think about your thoughts feelings and behavior DUR
92. ons was set as the initial guideline for referral to treatment in New York Referral acceptance increased linearly with the number of intense reactions until it peaked and stabilized at seven intense reactions 85 percent acceptance This result led to a working 3 7 rule for the Sprint E with three suggesting possible and seven probable treatment need The validity of the 3 7 rule was supported in a sample of help seeking adults in Florida after the 2004 hurricanes Tested against the PTSD Checklist the Sprint E performed well in receiver operating characteristic or ROC analyses area under the curve 87 a score of seven achieved sensitivity of 78 percent and specificity of 79 percent The Sprint E was subsequently used in a treatment program for Katrina survivors sponsored by the Baton Rouge Area Foundation in collaboration with the Baton Rouge Crisis Intervention Center and the National Center for PTSD The Sprint E was administered at the point of referral and at four subsequent time points Participants scores decreased greatly during the course of treatment and improvements were maintained at 4 month follow up The Sprint E s reliability and sensitivity to change was also evidenced in a study of specialized crisis counseling services in Mississippi References are at the end of this section How is the Adult Assessment and Referral Tool scored The tool is scored by counting the number of reactions valued 4 quite a bit or
93. or twice during the course of an RSP a 1 or 2 week period is chosen and all appropriate persons are asked to complete an anonymous survey In larger programs different areas could be surveyed in consecutive weeks The number of survey respondents is compared to the total number of eligible adults served in individual crisis counseling or group crisis counseling not including public education groups during that period to estimate the response rate How is the survey done During the selected period for data collection all appropriate persons are given a nice looking packet containing a cover letter signed by the Program Director the survey a good quality black ink pen anda stamped preaddressed envelope for returning the survey The packets are to be distributed to supervisors 1 week in advance and supervisors give crisis counselors a set of packets to distribute A template for the cover letter and handouts for counselor training can be found in Component II of this toolkit or in the CCP Application Toolkit What is the counselor s role Crisis counselors distribute the survey The importance of the crisis counselor s attitude in this process cannot be overstated The counselor must view this survey as the recipient s opportunity to tell the program anonymously how he she feels about the services and his her reactions Counselors might introduce the survey by saying that this week program leaders are making a special effort to learn about
94. ormation needed to describe them group crisis counseling and public education are captured on the same one page form The crisis counselor will check one box if the encounter was group counseling and another if it was public education The log has four parts Part 1 Basic Information Similar to the Individual Encounter Log the first part collects information on the program such as project number FEMA disaster response number DR XXXX State provider name if not the State assigned provider number employee number service date county code of service and zip code of service delivery This information will normally be prepopulated or already filled out on the form by the lead data staff except for the type of activity Part 2 Characteristics of Encounter The second part collects information on the location of the encounter and its session number first session of a group expected to meet once first session of a group expected to meet more than once or a second or later session of an ongoing group The estimated number of participants and the duration of the encounter are also to be recorded Part 3 Group Identities This section basically asks What makes the group a group Options are provided for the crisis counselor to mark with a check if a group consisted only or mostly of children or youth adults public safety workers first responders or other recovery workers There is also an option to select if a group encounter was c
95. out that everything they need is inside the packet the survey a pen and a stamped envelope to use to mail it back in You should mention that the survey doesn t ask for their names and is completely anonymous What should you do if the person needs or asks for help completing the survey The reading level of the survey is approximately fifth to sixth grade Some people may not be able to read at this level or for some other reason language visual impairment will need help to complete the survey Unfortunately you cannot help them If someone asks you for help you might tell them that you would really like to help but you ve been told not to because the people doing the survey need to be sure that counselors haven t influenced the results Please use this as an occasion to help the participant think about other sources of potential help Is there a family member who could read them the questions Could a friend It might be a good idea to practice how you will handle this Also there could be occasions when you think people might need help even if they didn t ask for it When you introduce the survey you might tell them that many people prefer to have a family member or friend read them the questions so that they can think only about the answers What should you do if the person implies that they shouldn t be the one to complete the survey Sometimes people think they aren t the right people to participate They might say for examp
96. person in your agency who will review and sign the form Thank you for taking the time to complete this form accurately and completely Public Burden Statement 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 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 2 minutes per client per year 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 OMB NO 0930 0270 PROJECT Expiration Date 01 31 2012 Weekly Tally Sheet Brief Educational and Supportive Services Not Elsewhere Included Provider Name County or Parish 3 digit FIPS code Provider Number Week beginning MM DDIYYYY Employee ID NUMBER OF CONTACTS OR NUMBERS DISTRIBUTED TYPE OF CONTACT SUN MON TUES WED THURS FRI SAT TOTAL In person brief educational or NA PP yr Tr 7 supportive contact Telephone contact E mail contact y 5 FA m m m i Material handed to people wit
97. r herself the counselor or provide a referral if the child youth is in need of specific support or intervention In the Referral section check the type of referral made if the person child youth accepted the referral and if the parent caregiver accepted the referral How is the Child Youth Assessment and Referral Tool introduced by crisis counselors Prior to administration of the Child Y outh Assessment and Referral Tool make sure that consent was obtained from a parent caregiver for the child s or youth s participation in the CCP For children over the age of 7 read the following instructions Occasionally we find it helpful to ask children adolescents a few questions about how they were affected by the disaster and how they are feeling now May ask you these questions My first questions are about various experiences you have had in the disaster For children 0 7 it is recommended that a parent caregiver be interviewed with the child present Cohen Kelleher amp Mannarino 2008 Scheeringa amp Haslett 2010 When there are concerns about the ability of a child over the age of 7 to understand and accurately answer the questions itis advisable for the parent caregiver to assist in answering the questions Adolescents may not want to be interviewed in front of their parents If a parent caregiver is present ask the adolescent if they wish to be interviewed alone How are child youth symptoms assessed The symptom
98. r kill yourself M no T yes REFERRAL INSTRUCTIONS IF THE ANSWER TO ITEM 12 IS YES REFER FOR IMMEDIATE PSYCHIATRIC INTERVENTION IF THE ANSWER TO ITEM 12 IS NO CONTINUE IF SCORE IS 3 OR HIGHER READ FROM WHAT YOU HAVE TOLD ME IT SEEMS THAT YOU MIGHT BENEFIT FROM PARTICIPATING IN ANOTHER SERVICE DESCRIBE WOULD LIKE TO REFER YOU TO __ IF SCORE IS BELOW 3 READ FROM WHAT YOU HAVE TOLD ME IT SEEMS THAT YOU ARE MANAGING YOUR REACTIONS DOES THAT SEEM RIGHT TO YOU IF NO READ PERHAPS YOU WOULD BENEFIT FROM PARTICIPATING IN ANOTHER SERVICE DESCRIBE WOULD LIKE TO REFER YOU TO IF YES READ WE SHOULD DECIDE UPON SPECIFIC GOALS FOR COUNSELING THAT WE CAN MEET TODAY OR WITHIN ANOTHER COUPLE OF VISITS REFERRAL select all that were communicated C other crisis counseling program services e g group counseling team leader follow up community services e g FEMA loans housing employment social services m mental health services e g professional longer term counseling treatment behavioral or psychiatric services other specify in box gt A substance abuse services e g professional behavioral or Note what the referral was for not where it was made to medical treatment or self help groups such as AA or NA Did the participant accept one or more of the referral s E no E yes INSTRUCTIONS ADULT ASSESSMENT amp REFERRAL TOOL When to Use This Form This form is used as an int
99. r or outreach worker on the following areas In the boxes at right please X the box that best represents your opinion where 1 is the worst rating and 10 is the best rating Worst Best How good was the information you got on how people feel after 1 2 3 4 5 6 7 8 9 10 disasters Was that information the best it could be 10 the worst it could be 1 or somewhere in between 2 9 How good of a job did the counselor or outreach worker do helping you to know that your feelings after the disaster were 1 2 3 4 5 6 7 8 9 10 the same as many other people s feelings How good of a job did the counselor or outreach worker do 1 2 3 4 5 6 7 8 9 10 treating you with respect How good of a job did the counselor or outreach worker do 1 2 3 4 5 6 7 8 9 10 respecting your culture race ethnicity or religion How good of a job did the counselor or outreach worker do 1 2 3 4 5 6 7 8 9 10 making you feel that asking for help is okay How good of a job did the counselor or outreach worker do 1 2 3 4 5 6 7 8 9 10 making you feel that you can help yourself and family id How good of a job did the counselor or outreach worker do 1 2 3 4 5 6 7 8 9 10 keeping things you said private How good of a job did the counselor or outreach worker do helping you to find ways to tak
100. r the county or parish where the group was held ZIP CODE OF SERVICE The zip code of the location you had the encounter in LOCATION OF SERVICE Where did you provide the service SELECT ONLY ONE SESSION NUMBER Select the number of group encounter session SELECT ONLY ONE NUMBER OF PARTICIPANTS Use all 4 boxes to report the number of participants not including staff and to estimate their age distribution For example for 7 participants with no adolescents 3 adults lt 65 and 4 older adults write in O 3 4 7 DURATION How long did your encounter last SELECT ONLY ONE If less than 15 minutes use the weekly tally form GROUP IDENTITIES This refers to the possible identities and or roles that the group members might share as a whole Primarily means that the majority of group members shared the listed characteristic For example a group focused on children that had a few adults present would meet the definition of a group composed only or mostly of children Groups do not necessarily have an identity If so check the last box FOCUS OF GROUP SESSION What is the focus of the group encounter SELECT ALL THAT APPLY If the focus for the group is different than the categories listed please select OTHER and fill in the blank with the focal point REVIEWER Team lead or direct supervisor to review completed form for accuracy and then sign and date date of review Please submit the completed form to the designated
101. rage will submit 30 form pages each week for data entry Allow 90 seconds per form to estimate staff time for manual data entry How are the data analyzed The CCP Online Data Collection and Evaluation System website has reporting functions that correspond to results required on the RSP quarterly reports The CCP Online Data Collection and Evaluation System website also allows for downloads of the data files so that they may be exported into statistical software such as Statistical Package for the Social Sciences or SPSS and SAS for additional analysis as warranted Is this evaluation enough This evaluation plan may or may not be enough depending upon the size and complexity of the program Good evaluators assist program planners and managers to identify other information needs specific to their locations that are not part of the evaluation required by the sponsor For example as the program unfolds innovative approaches may emerge that warrant special evaluation procedures that capture outcomes as well as outputs There could be occasions where the program needs qualitative data on selected focused issues In other words the plan described here provides basic information on service reach quality and consistency but does not preclude the possibility of States adding other components to their own program evaluations 26 gt SAMHSA DTAC Y Y S Component II CCP Data Collection Forms Instructions and Survey Templates project Indi
102. re you are strongly encouraged to build your own quality control measures within your program before you even begin to enter data in the system Upon submitting a form with blank values the confirmation page for that particular form will identify all fields that you have left blank These fields will appear in red and will have the word null next to the field label This formatting is indented to call your attention to blank values that you may have submitted erroneously so that you may then go back into the form to revise the data REVISING DATA Project DR TEST VA Provider Name Gulf Coast Center Employee 987654 Date of Service 5 22 2009 County of service 001 Accomack Location of Service community center Visit Type NULL Visit Number NULL Duration NULL Risk Categories home damage Age adult 18 39 Sex NULL Race NULL Ethnicity NULL Primary Language of Contact NULL Data can be revised via two methods 1 by using the link on the confirmation page as described in the Entering Data part of Section 3 2 immediately after submitting the form or 2 by using the search feature associated with each individual form to find and isolate individual records or sets of records Data can be edited as many times as necessary DELETING DATA The only users who can delete data from the system are the State z Disaster Mental Health Coordinator 1 and State data evaluation staff Using the sear
103. re not surveyed Hotline staff members also are excluded What s in the survey The two page survey has several parts The first section asks staff to evaluate the CCP trainings they have received The next section asks staff to evaluate the support supervision and opportunities for growth provided by the work This section also asks about the appropriateness of the workload and the adequacy of resources and tools available and for the provider s evaluation of the services provided by the CCP The section that follows is composed of five questions about stress These questions examine whether the work or the provider s reaction to it has caused problems in other areas of his or her life The survey requires management to include a phone number outside of the chain of supervision that counselors can call to receive assistance if they are feeling especially stressed A section on demographics and a place for comments complete this survey When and how is it done These data are collected anonymously from crisis counselors and their supervisors atroughly 6 and 12 months post event These time points typically occur within the RSP The survey is administered online in coordination with SAMHSA DTAC Paper administration is acceptable only when online administration is not possible For paper administration supervisors distribute a packet containing a cover letter the survey and a good black pen to each crisis counselor together with a stamped retu
104. required Two quarterly progress reports and one final report for the 9 month RSP grant must be submitted to FEMA and CMHS Project Officers and the SAMHSA DTAC technical assistance specialist Q uarterly reports are due 30 days after the end of the 3 month reporting period The final program report is due to the FEMA and CMHS Project Officers 90 days following the final day of program services Evaluation data are required in the quarterly reports and the final program report Please refer to the Notice of Grant Award letter and the terms and conditions of your grant award for guidance on the evaluation reporting requirements Who is responsible for this work Programs are responsible for entering the data from Individual Encounter Logs Group Encounter Logs Weekly Tally Sheets Participant Feedback Surveys and Adult and Child Y outh Assessment and Referral Tools Service Provider Feedback Survey data is entered directly into the CCP Online Data Collection and Evaluation System via a link provided to crisis counselors and team leaders 25 SAMHSA DTAC AS What resources are needed Total resources needed to conduct this evaluation vary greatly with program size It is estimated that each full time crisis counselor will need 40 forms each week a combination of W eekly Tally Sheets Individual Encounter Logs and Group Encounter Logs ata cost of 042 4 cents per form It is estimated that each full time counselor on ave
105. rn envelope addressed to an external evaluator Although the surveys may be handed out during a staff meeting they should be completed later so that crisis counselors do not feel pressured to participate Two weeks before the survey is distributed the Program Director should send an email or other notice e g letter to all crisis counselors and team leaders informing them of the forthcoming survey and explaining why it is important to complete it Two weeks after the survey is distributed the Program Director should send a thank you and reminder email or letter to all counselors and team leaders Templates for survey administration are included in Component II of this toolkit and in the CCP Application Toolkit How are counselors protected Some counselors could understandably be concerned that supervisors or Program Directors could figure out who they are even though the survey is completed anonymously However SAMHSA DTAC takes several precautions to guarantee anonymity to all CCP counselors F or those participating in the online survey no personal identification is required when taking the survey and all data is kept in a secure database and only reported at the aggregate level For paper administration the completed survey is mailed to an external evaluator so that it does not go through local program management Regardless of the number of workers provider surveys are collected for the cumulative national database Detailed results are share
106. rt collects demographic information including age sex race ethnicity and language of contact Part 5 Event Reactions The fifth part collects information on reactions to the disaster event that a person is currently experiencing at the time of the service encounter Specific events are categorized as behavioral emotional physical and cognitive reactions If a person is coping well due to the disaster event at the time of the service encounter then the crisis counselor can check the box indicating coping well none of the above applies Part 6 Referral Starting on page 2 of the form The sixth and final part of the Individual Encounter Log is referral If a crisis counselor has provided the person with a referral then he or she should indicate the referral type in this section A referral could be to another component of the CCP such as a Support group or to a team leader or senior professional for follow up The crisis counselor could also refer the consumer to other mental health services substance abuse services or community services such as other FEMA Individual Assistance programs housing unemployment if applicable When the other option is used the counselor should indicate the nature of the service rather than the agency to which the individual was referred All referrals for mental health or substance abuse services should be indicated in the previous corresponding boxes Reviewer Signature Block Once the team
107. s that can be used to interpret data from new programs A Y f Data Management and Analysis How are the forms produced The CCP data forms come in portable document format PDF The PDF versions of the forms can be photocopied and used immediately Because typical programs enter the data manually into the CCP Online Data Collection and Evaluation System website http www esi bethesda com CCP Evaluation the PDF set of forms can be used throughout the life of the program Itis a violation of OMB policies to change the forms in any way All forms are intended for duplex two sided printing The three forms that are used most often collect information and have instructions on the last page of the form Individual Crisis Counseling Encounter Log Group Encounter Log and Weekly Tally Sheet The instructions are part of the OMB approved form and should always be printed W hen possible the forms should be printed on both sides of one sheet of paper The assessment and referral tools are a 3 page form to allow for both the referral guidelines page 2 and general instructions page 3 Itis acceptable to reuse the instructions page for assessment and referral tools Larger programs start out like typical programs by photocopying the PDF logs and tallies for immediate use However if itis feasible larger programs may consult with their Federal Project Officers about purchasing a scanner and applicable scanning software Once approval is obtained from
108. s for reducing this burden to SAMHSA Reports Clearance Officer 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 HOW ARE WE DOING Y our opinion 1s important to us In month we will be distributing a link to an online survey to crisis counselors outreach workers and team leaders to get your feedback about name of your project This survey will help us to understand from your point of view how well our project 1s meeting the needs of staff and the community The survey 1s anonymous and will take only a few minutes of your time It is voluntary but we encourage you to participate so we can learn how to improve the program and the services we provide Again your opinions and experiences as a staff member of are important We appreciate the time you will take to complete this survey Thank you Date Dear name of Project staff member This survey will help us learn about your opinions and experiences with name of Project At this time we are giving this survey to crisis counselors outreach workers and team leaders who have been working with name of Project for one month or longer If you have not been working at the project for at least one month please do not complete the survey We may be doing this survey again in a few months and will seek your opinion at that time Please click on the following link or copy it into your web browser and you will find a brief anonymous feedback sur
109. scdscndedsaseadec egnnded alnaded sdandedsatendecddae 3 OWING tes Secs cacesxanicas sncevenecuaeven And ars 3 O O NR 4 2 3 SPECIAL FEATURES eenen i i ita 5 A NN 5 AUTOCA CUL IONS csata a A asateneebag 5 Contextual Help ICONS sciences lali data 6 Date Hilti iaa 6 Systemi Message Center iii ib 7 Redundant Field Auto Population 0 cccccecsecceceeeeeeeeeceaeceeeeeeeseceaaaeceeeeesescacaeeeeeeeeesensueaeeseeeeeetensaees 8 Validation seccion a dit 9 AAT Section 3 USING THE SYSTEM ooooocccccccnnoconocccocncooncoonnonnnconnnonnnonnnonnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnnns 9 3 1 SETTING UP A DISASTER CCP PROFILE sisscsssaccchsanctadesntedecavacuraununeeaccavacunede sated des EE 10 Intake Form eacszdies 02 cg cece Sa cece os cd e E a an Ped Gee ctesgaeectee Piedad ee aneian dened 10 Assign Employee s 2 ninlati daa cee a a ee 10 3 2 ENTERING AND MAINTAINING DATA 00 ccccccceccneceeecnneeeeeceeeeeecaeeeeecaeeeeesaeeeeecaeeeeessaeeeessneeeeess 11 Entering Datel msi is 11 Required FIGIGS viario A AA AAA ARA A AA 12 Revising Data cioiticontonia catala ita dat ni ia 12 Deleting Dala uri a EE A a ened cd A aa ahead 12 Search TOR FONS ii A A A AAA Ad A 13 3 9 GENERATING REPORTS teiaa aa sated des aa E e a a AA EEEE 13 CCP Evaluation Online Database Repott ccccccccceeeeeeecceeceeeeeeeeeceaeaeeeeeeeeesceaeaeeeeesesetennaeeeeeeeeeeees 13 Standard Progress Report iia a aid 14 CCP Evaluation Online Database Download
110. sis Counseling Services SCCS Final Program Evaluation Unpublished manuscript Scheeringa M amp Haslett N 2010 The reliability and criterion validity of the diagnostic infant and preschool assessment A new diagnostic instrument for young children Child Psychiatry and Human Development 41 299 312 Steinberg A M Brymer M J Decker K B amp Pynoos R S 2004 The University of California at Los Angeles Post traumatic Stress Disorder Reaction Index Psychological reports 6 96 100 Service Provider Feedback Survey What is the purpose of this survey Crisis counselors are the essential link between the program and the consumer Crisis counselors and their supervisors are in a unique position to judge the quality of the services being provided and the extent to which they match the needs of the community The Service P rovider Feedback Survey yields a standardized assessment of providers opinions and reactions to their work 21 Al SAMHSA DTAC Who is included The survey is intended for crisis counselors who provide direct face to face services to disaster victims This also includes their immediate supervisors team leaders who guide the crisis counselors work These workers are included regardless of the number of hours they work each week Itis administered only to workers who have performed these functions for one month or more Staff who play only administrative clerical or evaluation functions a
111. sis counseling on two or more occasions before this visit OR 2 with any child at any time if you suspect the child may be experiencing serious reactions to the disaster ENCOUNTER INFORMATION Provider Name Provider Employee Date of Service mm dd yyyy County Code of Service Zip Code of Service Visit Number 4st visit 2ndvisit 3rd visit 4th visit 5th visit or more Was parent or caregiver present during the visit Yes No READ Occasionally we find it helpful to ask children adolescents or their parent caregivers a few specific questions about how they were affected by the disaster and how they are feeling now May ask you these questions My first questions are about various experiences you have had in the disaster RISK CATEGORIES check all that apply family member missing or dead injured or physically harmed self or household evacuated quickly with no time to prepare friend missing or dead lifewas threatened self or household prolonged separation from family pet missing or dead witnessed death injury self or household displaced from home 1 week or more home damaged or destroyed assisted with rescue recovery self or household past substance use mental health problem vehicle or major property loss disaster unemployed self or household pre existing physical disability other financial loss had to change schools for children or youth past trauma
112. sis counselors to their supervisors on a weekly basis What do supervisors do Supervisors check the completeness of submitted forms and note errors When crisis counselors fail to follow the instructions the counselor should be shown what to do in the future It is likely that the most time consuming part of the supervisor s oversight is dealing with counselor errors so good counselor training is important Supervisors sign initial or stamp each form to show that it has been checked The supervisor designates a spot for the checked forms bundling together forms of a specific type e g Individual Crisis Counseling Services Encounter Log What happens next Local procedures vary according to the needs and size of the program Often a designated evaluation coordinator or some other courier is responsible for visiting each location to pick up the bundles of completed tools In geographically dispersed programs shipping the forms to a central location is recommended How are the data entered The data are entered in the CCP Online Data Collection and Evaluation System website at http www esi bethesda com CCP Evaluation Please refer to the online CCP Online Data Collection and Evaluation System User Manual Version 2 0 that is also Component III of this toolkit For technical assistance regarding CCP data forms or data entry via the online system please contact SAMHSA DTAC at 1 800 308 3515 or DTACO samhsa hhs gov What reports are
113. ssment and Referral Tool onnnnninininnninnninccnncnccnnicnran crac nano n noni 19 Referral Component a a 20 How is the Child Y outh Assessment and Referral Tool introduced by crisis counselors 20 How are child youth symptoms assessed 0 cece eee ete tte tee eee rr rr 20 ls THE MCASUFE JODA aroeira e eater anna aden eaves 21 OWS it SCORSU ii A A oiled A A E 21 Is the Individual Encounter Log used t00 oo cece terete eet etter teeter rro 21 References Child Y outh Assessment and Referral Tool ccccccccccccccccecsssseseeeececcecssssueeeeeueessessuanens 21 Service Provider Feedback SUIVCY cece tet ete eee eee nr rre rr rre 21 Wihatis the purpose Of this SUVGY sicdientnicinnde anid nant detainee 21 VINOS MUA ii A a caca 22 Whats In th SUSY isis aa cc 22 When and ROWIS ICAONE Romain e A E ran 22 How are counselors protected rta a aT aaa 22 Participant Feedback SUIVOY iii ide ad dt 22 What is the Participant Feedback Survey ounniiciinionccinncnoncconncan acarrear 22 Whyisthis necessary ii ica 23 To Wwhomis the Survey GIVEN Postre abia 23 When Is the SUVEY CONG ici rd 23 HOW IS TE survey CONG mirra di ota 23 Whatis the counselors rOle viciado 23 How are counselors protected veta A a aes 24 Aren t satisfaction data biased oo siano i ai aaa 24 AAT Data Management and AnalySis cccccccscssssssscesscssscessscrssceesceesseseseesseesseasseaeseasseaessessertesseesgs 24 How are the forms PO UCA siii A
114. t are the roles of States and or service providers funded with a CCP CCP services are typically provided to the affected areas by behavioral health organizations through contracts with a State s department of mental health In some cases crisis counselors are hired directly as State employees CCP staff members usually include a combination of behavioral health professionals and paraprofessionals trained and supervised to deliver an array of crisis counseling services CCP staff members are uSually indigenous to the affected communities and are sometimes survivors themselves The CCP funded State U S Territory or federally recognized Tribe is tasked with ensuring that CCP services reporting requirements and financial documentation adhere to Section 416 of the Robert T Stafford Disaster Relief and Emergency Assistance Act Public Law 93 288 as amended Why is it important to collect consistent data on CCP services Collecting accurate information about services and service recipients is essential for monitoring and evaluating CCPs In the past States developed their own procedures and forms This process was time consuming and often missed important questions CMHS recognized that standard reporting methods needed to be implemented in order to make the data meaningful and more accurate across disasters and across States U S Territories and federally recognized Tribes In 2005 CMHS introduced a data toolkit to standardize program activiti
115. t happened 3 To what extent have you lost enjoyment in things kept your distance from people or found it difficult to 1 2 3 4 5 experience feelings because of what happened Mm Mm i r E 4 How much have you been bothered by poor sleep poor concentration jumpiness irritability or feeling 1 2 3 4 5 watchful around you because of what happened Mm m Mm Mm Mn 1 2 3 4 5 How down or depressed have you been because of what happened A E TARRI 1 2 3 4 6 Has your ability to handle other stressful events or situations been harmed Mm Mm Mm E nm 7 Have your reactions interfered with how well you take care of your physical health For example are you 1 2 3 4 5 eating poorly not getting enough rest smoking more or finding that you have increased your use of nm Mm Mm nm nr alcohol or other substances 1 2 3 4 5 8 How distressed or bothered are you about your reactions m 9 How much have your reactions interfered with your ability to work or carry out your daily activities such 1 2 3 4 5 as housework or homework nm 10 How much have your reactions affected your relationships with your family or friends or interfered with 1 2 3 4 5 your social recreational or community activities nm 11 How concemed have you been about your ability to overcome problems you may face without further 1 2 3 4 5 assistance NUMBER OF RESPONSES OF 4 OR 5 this is recipient s score gt gt gt gt 12 l also need to ask Is there any possibility that you might hurt o
116. t number FEMA disaster response number DR XXXX State provider name if not the State assigned provider number employee number service date county code of service and zip code of service delivery The county code is the last three digits of the Federal Information Processing Standards FIPS code This information will normally be prepopulated or already filled out on the form by the lead data staff for each crisis counselor or outreach worker staff member Part 2 Characteristics of Encounter The second part collects information on the characteristics of the encounter This includes information of the location of the service place visit type with one person or with two or more individuals who are a family visit number first time or follow up with anyone from the program and duration of the encounter Please note that a Family visittype may include married or unmarried heterosexual gay lesbian bisexual or transgender individuals One Individual Crisis Counseling Services Encounter Log is filled out for each active participant during a family visit Part 3 Risk Factors The third part collects information on risk factors These are factors that individuals may have experienced or have present in their lives that could increase their need for crisis counseling or outreach services Most of these risk factors are a result of the survivor s disaster experience 13 Al SAMHSA DTAC Part 4 Demographic Information The fourth pa
117. ta 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 1 Choke Cherry Road Room 7 1044 Rockville Maryland 20857 PROJECTE Group Encounter Log o Expiration Date 01 31 2012 TYPE of SERVICE Select one first before completing this log GROUP COUNSELING PUBLIC EDUCATION a group meeting where participants did most of the talking a presentation or group meetin g where YOU did most of the talking Provider Name Provider Employee Date of Service mm dd yyyy County Code of Service Zip Code of Service CHARACTERISTICS of ENCOUNTER LOCATION of SERVICE select one school amp child care all ages through college home temporary or permanent residence including friend family home group homes including houses apartments trailers and other dwellings community center e g government recreation social services retail e g restaurant mall shopping center store provider site agency involved with CCP medical center e g doctor dentist hospital mental health specialty workplace e g office workers public safety public place event e g street sidewalk town square fair festival sports other specify in box gt SESSION NUMBER select one tst session of group expected to
118. taff is the Intake Form This form is used to establish a disaster within the system so that other data entry tasks may be completed by State level users The Intake Form consists of two sections one for Federal data entry and one for State data entry Federal Data Entry Section The top part of the form is where the Federal Project Officer enters information for a specific disaster The following are minimum fields required to submit the form Disaster number State Provider name ISP or RSP State Data Entry Section The bottom part of the form contains fields that will be completed by the State Disaster Mental Health Coordinator for the particular disaster The data for these fields can be viewed and updated by the Federal Project Officer if necessary The Coordinator can access the Intake Form from the homepage which shows a list of active disasters The top part of the form is pre populated with data from the Federal level but the State Disaster Mental Health Coordinator will need to enter the following data at the bottom of the form Number of staff Number of team leaders Number of outreach workers Dates of program Estimated number of people to be served through primary services requires data entry of target numbers for each county in the State impacted by a particular disaster This information can be found in the ISP and RSP applications ASSIGN EMPLOYEE The Assign Employee function is available to the Sta
119. te Disaster Mental Health Coordinator who can use it to enter new employees into the system This feature allows for the identification and management of employees in the system SAMHSA DTAC will send an email indicating username and password for those employees authorized to log into the system State Disaster Mental Health Coordinators can also assign employees to particular disasters track if they have the necessary training and indicate whether they are an active or inactive member of the State s team within the system All of these operations are accomplished via online form pages Identifying employees and assigning them to disasters is the first step in giving them access to the system and permitting their name to show up in the various drop down lists and points for auto population Authorized employees need to have their own unique login to access the system User Manual Version 2 0 Page 10 of 15 SS SAMHSA DTAC ms Online CCP Data Collection amp Evaluation System User Manual 3 2 ENTERING AND MAINTAINING DATA From the navigation bar on the left side of the screen users can select a particular form to either enter new form data or search past entries Home Administration Assign Employee Individual Crisis Counseling Services Encounter Log Group Encounter Log Weekly Tally Sheet Adult Assessment amp Referral Tool Child Youth Assessment amp Referral Tool Service Provider Feedback
120. the Federal Project Officers the CCP should contact SAMHSA DTAC for the data coding manual It is expected that once data are scanned into a data file the data file will be uploaded to the CCP Online Data Collection and Evaluation System website so that the program will still have the availability to access data and use the data analysis and reporting functions of the CCP Online Data Collection and Evaluation System website http www esi bethesda com CCP Evaluation How are the forms filled in The tools have been designed to require little more than numbers or Xs in boxes that correspond to the selected answer The marks should be made firmly and neatly with a good quality black ballpoint rollerball uni ball or gel pen 24 SAMHSA DTAC Where do completed tools go Crisis counselors turn in completed Individual Encounter Logs Group Encounter Logs Weekly Tallies Adult Assessment and Referral Tools and Child Y outh Assessment and Referral Tools to their supervisors Participants mail their surveys to the State s evaluation coordinator and providers mail their surveys to an external evaluator How often are they submitted Programs can decide whether completed Individual Encounter Logs and Group Encounter Logs are to be submitted daily or weekly to the data entry staff In large programs serving many people it is better to do this on a daily basis so that the work does not pile up W eekly Tally Sheets are submitted by cri
121. the needs of the community and how counselors are helping to meet those needs Counselors might furthermore note that the survey is short and should take only a few minutes of the person s time Counselors who view this as a burden 23 A SAMHSA DTAC will convey that attitude to potential respondents It is essential that this form be given to each service recipient who should get it Only then will the information be meaningful and useful to the program How are counselors protected Some crisis counselors could understandably be concerned that the survey might be used to evaluate their own performance rather than that of the program as a whole Additionally some crisis counselors work in areas where survivors might be angry in general and could get lower ratings through no fault of their own Although the questions refer to the counselor the survey does not name a particular crisis counselor The data are examined only in groupings defined by county or respondent characteristics Aren t satisfaction data biased The positive bias in consumer satisfaction measures is well documented People tend to answer in high ranges on consumer Satisfaction surveys even when they have not improved The tool addresses this bias by using a wide response format that allows room for variation Recipients answer each question on a 10 point scale where 1 is the worst rating and 10 is the best rating Over time the pooled data have provided norm
122. vey link As direct service providers you experience firsthand the effectiveness of the program we have put into place We want your opinion about the training resources and opportunities for support provided to you on the job We also want to know how you view the quality of services the project provides We know that you as someone on the front lines understand the project through your direct experience which makes your feedback especially helpful and relevant In addition there is a portion of the survey that checks in with you about the stress this job can sometimes bring If you feel you need some additional support please call phone number You will be taking this survey anonymously and therefore will not be asked for your name or any other identifying information beyond your provider s name The results will only be given for large enough groups of crisis counselors to make sure that no individual counselor is identified These steps are taken so that you may freely express your honest opinion We encourage you to complete this survey by Date However your participation in this survey is completely voluntary You will not be penalized if you choose not to participate Also you should feel free to leave any question blank that you do not wish to answer Y our opinions about your experiences with name of Project are important to us Thank you for taking the time to complete this survey Sincerely Date Dear na
123. vey given During the selected survey week the questionnaire is to be given to ALL adults receiving in person individual or group crisis counseling These are generally the same people for whom you would complete an Individual Crisis Counseling Services Encounter Log or a Group Encounter Log for group crisis counseling The survey is NOT to be given to people who would be recorded as receiving a brief supportive or educational encounter on the Weekly Tally Sheet or public education on the Group Encounter Log and it is not given if the counseling occurred over the telephone The survey is also not for people less than 18 years of age Also only people who are counseled during the week selected for the survey are being asked to participate We know you have helped many many people over the course of the project You may see some people this week who seem less typical or perhaps less appreciative than some people you saw last week Please don t be concerned about this These variations will average out over the various counselors who are passing out the survey It is critical that these instructions are always followed There will be times when you will be sure that the participants will not complete the survey You might even think it is wasteful to give them a packet when you know they won t do it Participating is their choice to make not yours Please give a packet to each person who meets the sample definition When should you give t
124. vidual Crisis Counseling Services Encounter Log o Bie Provider Name Provider Employee Date of Service mm dd yyyy County Code of Service Zip Code of Service CHARACTERISTICS of ENCOUNTER LOCATION of SERVICE select one school amp child care all ages through college ie ome temporary or permanent including friend or family homes group a hool amp child all th h college h t t including friend or family h f homes including houses apartments trailers and other dwellings community center e g govemment recreation social services M IF HOME PLEASE CHECK THIS BOX IF ANY provider site agency involved with CCP CHILDREN lt AGE 18 LIVE IN THIS HOME phone counseling 15 minutes or longer including hot lines 4 life lines disaster recovery center e g FEMA Red Cross medical center e g doctor dentist hospital mental health specialty place of worship e g church synagogue mosque El m workplace e g office workers public safety m public place event e g street sidewalk town square fair festival sports a retail e g restaurant mall shopping center store other specify in box gt VISIT TYPE Individual Family 2 or more related individuals please complete one form for each active participant VISITNUMBER 7 ist visit 2nd visit 3rd visit 4th visit 5th visit or more DURATION 15 29 minutes 30 44minutes 45 59minutes 60 minutes or more
125. we aim to serve This information could lead to program adjustments to meet previously unrecognized needs Third the survey helps planners learn about factors that influence perceptions of service quality For example are highly distressed individuals more or less positive about services than are less distressed individuals Are members of different ethnic groups equally likely to report that they were treated with respect and sensitivity How is the survey NOT used The survey is NOT used to evaluate the work of individual counselors To make survey questions easier for respondents to grasp they refer to the counselor but the survey does not name a particular crisis counselor The data are examined only in large groupings defined by State region or participant characteristics Will the questions upset people There is much evidence that people are not upset by questions about distress Disasters upset people not questions about disasters Still it is possible that answering a set of questions about distress levels may cause some people to realize that they are not coping as well as they d like For this reason the survey includes a phone number to call if people are concerned about their answers to the stress questions You should not feel uncomfortable about this at all The worst case scenario is that some people may become more aware of their emotional reactions and this is not inappropriate in the context of a CCP To whom is the sur
126. y see it Surveys are to be mailed to the following address Substance Abuse and Mental Health Services Administration Disaster Technical Assistance Center To the attention of DTAC staff 4350 East West Highway Suite 1100 Bethesda MD 20814 The results will only be given for large enough groups of crisis counselors to make sure that no one counselor is identified These steps are taken so that you may freely express your honest opinion We encourage you to fill out this survey and send it in by date However your participation in this survey is completely voluntary You will not be penalized if you choose not to participate Also you should feel free to leave any question blank that you do not care to answer Your opinions about your experiences with name of Project are important to us Thank you for taking the time to complete this survey Sincerely Date Dear name of Project staff member If you have completed our feedback survey of name of Project crisis counselors outreach workers and team leaders we thank you for your participation The feedback received from you will help us to improve our services not only to the community but also to our employees and partners We may be implementing this survey again in a few months in an effort to monitor our progress and to continually address staff concerns that may arise If you have not yet filled out the survey please do so by date so your opinion and experienc

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