Cost

OMB Approval # 0990-0XXX

Expiration Date: XX/XX/2018

Cost

• Indicate the total amount paid to the program developer or distributor during this grant year by either the grantee or any subcontractors:

• What types of materials, supports, and/or services were covered by this payment to the program developer or distributor during this grant year (check all that apply)?

Program materials and supplies
Licensing fees
Pre-implementation training or technical assistance
Refresher training or ongoing technical assistance
Fidelity monitoring or quality improvement services
Other specify:

• Apart from any payments made to the program developer or distributor, indicate the total amount paid during this grant year by the grantee or any subcontractors for each of the following:

Program materials and supplies		$
Contracted pre-implementation training or technical assistance		$
Contracted refresher training or ongoing technical assistance		$
Contracted fidelity monitoring or quality improvement services		$

• Indicate the total amount paid during this grant year by the grantee or any subcontractors for the following recruitment and retention materials and activities:

Monetary incentives, including gift cards, for program enrollment or participation		$
Non-monetary incentives for program enrollment or participation (t-shirts, etc.)		$
Program supports (meals, transportation, etc)		$
Program recruitment materials		$
Media campaigns		$
Other specify:		$

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0XXX. The time required to complete this information collection is estimated to average 0.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.