Program Fidelity Checklist

Federal Evaluation of Making Proud Choices! (MPC!

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0990-0452 can be found here:

Documents and Forms

Document Name Document Type
Instrument 5_Fidelity Facilitator Log.docx Other-checklist

Information Collection (IC) Details

IC Title:	Program Fidelity Checklist	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-checklist			Instrument 5_Fidelity Facilitator Log.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 17	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	238	238
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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