Information Collection

Q-DOT Pilot Study

IC 209922 under ICR 201410-0970-005 · OMB 0970-0355.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Q-DOT Pilot Study

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	60	60
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.