Q-DOT Pilot Study

Pre-testing of Evaluation Surveys

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0355 can be found here:

Documents and Forms

Document Name Document Type
Attachment A1 - Q-DOT - Program Recruitment Script.track changes(kr).docx Other-Screener
Attachment A1b QDOT Center Director SAQ (formatted by RD 12-2-13).docx Other-Questionnaire
Attachment A2 QDOT Teacher SAQ2 (formatted by RD 12-2-13)(kr).docx Other-Questionnaire
Q-DOT - Section A_TO OMB_FINAL_v2.docx Q-DOT - Section A_TO OMB_FINAL_v2 IC Document
Q-DOT - Section B_TO OMB_FINAL_v2.docx Q-DOT - Section B_TO OMB_FINAL_v2 IC Document
Appendix B1 - Q-DOT FAQs_v2.docx Appendix B1 - Q-DOT FAQs_v2 IC Document
Appendix B2 - Q-DOT Teacher Cover Letter.docx Appendix B2 - Q-DOT Teacher Cover Letter IC Document
Appendix A1 - Q-DOT Center Recruitment Letter_v2.docx Appendix A1 - Q-DOT Center Recruitment Letter_v2 IC Document
Appendix B3 - Q-DOT Center Director Cover Letter_v2.docx Appendix B3 - Q-DOT Center Director Cover Letter_v2 IC Document

Information Collection (IC) Details

IC Title:	Q-DOT Pilot Study	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Screener	Attachment A1 - Q-DOT - Program Recruitment Script.track changes(kr).docx	No	No	Fillable Fileable
Other-Questionnaire	Attachment A1b QDOT Center Director SAQ (formatted by RD 12-2-13).docx	Yes	Yes	Fillable Fileable
Other-Questionnaire	Attachment A2 QDOT Teacher SAQ2 (formatted by RD 12-2-13)(kr).docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 60	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	60	0	0	0	0	0
Annual IC Time Burden (Hours)	20	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Q-DOT - Section A_TO OMB_FINAL_v2	Q-DOT - Section A_TO OMB_FINAL_v2.docx	12/17/2013
Q-DOT - Section B_TO OMB_FINAL_v2	Q-DOT - Section B_TO OMB_FINAL_v2.docx	12/17/2013
Appendix B1 - Q-DOT FAQs_v2	Appendix B1 - Q-DOT FAQs_v2.docx	12/17/2013
Appendix B2 - Q-DOT Teacher Cover Letter	Appendix B2 - Q-DOT Teacher Cover Letter.docx	12/17/2013
Appendix A1 - Q-DOT Center Recruitment Letter_v2	Appendix A1 - Q-DOT Center Recruitment Letter_v2.docx	12/17/2013
Appendix B3 - Q-DOT Center Director Cover Letter_v2	Appendix B3 - Q-DOT Center Director Cover Letter_v2.docx	12/17/2013

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.