Fidelity Evaluation-Site Survey

Evidence Based Program Fidelity Survey
Site Survey
General Instructions
Thank you for participating in this important effort to collect data on behalf of the Administration for
Community Living (ACL) on the ways in which ACL grantees, State Units on Aging (SUA), and
subcontractors/partners ensure that evidence based programs (EBPs) are implemented and sustained with
fidelity to the program developers’/administrators’ models. By fidelity, we mean the extent to which
organizations take steps to be sure that their offered programs are implemented according to the directions
of the program developer/administrator. This survey will take approximately 30-40 minutes to complete.
Some sections of the survey have specific instructions about how the questions should be interpreted and
responded to. Please read these instructions in order to ensure that we are able to accurately capture your
responses describing practices and experiences with regard to selecting, administering, and/or delivering
EBPs with fidelity.

Section 1. General/Screening Items
Instructions
Your organization may be involved in delivering one or more EBPs to the public. For the purposes of this
survey, please think only about as you respond to questions.
In this section, please focus on your general practices prior to the Coronavirus Disease 2019 (COVID-19)
Public Health Emergency (PHE), unless your organization began providing during
the PHE. In that case, please focus on your current practices.
1. Which of the following best describes your organization’s history of providing EBPs funded by ACL:
a. Offered prior to the PHE, but stopped due to the PHE
b. Offered prior to the PHE, and continued at least some programming during the PHE
c. Began offering services during or after the PHE
d. Unable to begin services due to PHE
2. Your organization is included in this survey because it is receiving grant funding from ACL to deliver
. Does your organization receive grant funding directly from ACL or is it a
subcontractor/subgrantee/or partner to another organization that receives grant funds from ACL?
a. Receives funds directly from ACL
b. Does not receive funds directly from ACL
c. Not sure

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Section 2. Selecting Evidence Based Programs
Instructions
We are interested in knowing how you select evidence-based programs. ACL requests that each question be
answered by someone with a good working knowledge of the topic at hand to ensure that the information
you supply is complete and accurate. For sections where someone else’s input would be most appropriate,
please enlist their assistance.
3. Who has input in the selection of programs? (Check all that apply)
a. Funder dictates
b. Leadership determines which programs to select
c. One or more inhouse staff members oversee selection of programs
d. Committee or multidisciplinary process seeks input from across the organization
e. External partners, subject matter experts, or consultants
f. State or local government guidance (e.g., state units on aging)
g. Participation with peers and partners in planning or learning network
h. Recommendations/requests of public
i. Other
4. What information sources do you consider in selecting appropriate EBPs for your community and
organization? (Check all that apply)
a. Internal policies
b. The Aging and Disability Evidence-Based Programs and Practices initiative (ADEPP), the
National Council on Aging’s (NCOA) list of EBPs funded through the Older Americans Act
Title III-D and approved through the Evidence-Based Programs Review Process, the EvidenceBased Leadership Collaborative (EBLC) program menu and/or some other evidence-based
program registry or webpage
c. Funder direction
d. Past experience
e. Community needs/interests
f. Other
5. Please indicate how important the following resource factors are in the selection process:
Please rate factors between 1 and 5, where 1 = not at all important and 5 = extremely important
a. Licensing costs
b. Staffing required
c. Training costs
d. Special equipment costs
e. Availability of facility space
f. Participant recruitment costs
g. Data collection and reporting costs

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6. Please indicate how important the following program-specific characteristics are in the selection
process:
Please rate factors between 1 and 5, where 1 = not at all important and 5 = extremely important
a. Program design (e.g. discussion group, class structure, hands-on activities)
b. Program content
c. Program flexibility/adaptability
d. Strength of the evidence base for the program (e.g., highest tier, strength of literature)
e. Availability of training
f. Supports for implementation (e.g., contains instructions/materials for maintaining quality
assurance, fidelity checklists)
g. Supports for dissemination (e.g., contains instructions/materials for reaching out to population,)
h. Readiness for remote delivery (contains instructions, materials for on-line, telephonic
programming)
i. Support/technical assistance provided by the program developer/administrator
j. The applicability or cultural appropriateness of the program to the community we serve
k. The degree to which we have staff/volunteers who already know how to implement the program
l. Program length (e.g. number of sessions, length of sessions)
m. Other
7. Please indicate how important the following population-specific characteristics are in the selection
process:
Please rate factors between 1 and 5, where 1 = not at all important and 5 = extremely important
a. Specific health needs
b. Languages spoken
c. Cultural diversity (e.g. racial/ethnic groups, tribes)
d. Special populations (e.g. veterans, low income)
e. Disability status
f. Urban/rural status
g. Other
8. Which of the following could be a significant help to your organization in the program selection
process? (Check all that apply)
a. Comprehensive and comparable estimates of program costs
b. Simpler program guidelines
c. Standardized program guidelines
d. Greater information about program flexibility—the capacity to accommodate local adjustments
without affecting fidelity and effectiveness
e. Other (Please specify): __________________________________________________________

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Section 3. Ensuring Fidelity to the EBP
Instructions
We are interested in knowing how you maintain fidelity to different aspects of the program model for the
. ACL requests that each question be answered by someone with a good working
knowledge of the topic at hand to ensure that the information you supply is complete and accurate. For
sections where someone else’s input would be most appropriate, please enlist their assistance.
[If you are a subcontractor/subgrantee/partner to a grantee answer Question 9. All others skip to Question
10]
9. Does require that you provide documentation that you are implementing
with fidelity?
a. Yes
b. No
10. How does your organization stay informed about approaches and methods for establishing and
maintaining program fidelity with regard to ? (Check all that apply)
a. Participate in program networking group
b. Participate in broad health related networking group (e.g. falls prevention)
c. Receive updates from program developer/administrator (e.g., via email group or list)
d. Check ACL/NCOA Websites
e. Other
11. What strategies does your organization use to assure faithful delivery of ?
(Check all that apply)
a. Regularly observe trainers/leaders during sessions
b. Collect feedback from trainers/leaders
c. Collect feedback from participants
d. Use services provided by program developer/administrator
e. Hold regular management strategy sessions regarding fidelity
f. Hold regular staff meetings and/or trainings that stress fidelity
g. Regular standardized review of program fidelity
h. Informal review of program fidelity as needed
i. Other

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[If Question 11 = g, answer Question 12. All others skip to Question 13.]
12. Who created the guidelines for the review process? (Check all that apply)
a. Your organization
b. Partners at the local or state level
c. Association or collaborative of EBP implementers
d. The program developer/administrator
e. The state/SUA
f. Other organization such as the National Council on Aging (NCOA), Evidence Based
Leadership Collaborative (EBLC)
g. Other
13. How often do you confirm that is being implemented according to the program
models?
a. When the program was first offered
b. Each time the program is offered
c. Monthly
d. Quarterly
e. Annually
f. Other
14. What challenges have you encountered to maintaining fidelity for ? (Check all
that apply)
a. Cost of monitoring fidelity
b. Time burden of monitoring fidelity
c. Lack of internal expertise on maintaining fidelity
d. Inadequate guidance from program developers/administrators
e. Lack of agreement among stakeholders on the importance of fidelity
f. Other
g. None [If g is selected, no other responses should be selected.]
15. What materials or tools would most help your organization overcome fidelity challenges?
a. User friendly fidelity maintenance guidance
b. Fidelity checklists
c. Fidelity training courses for managers
d. Trainer registry
e. Other

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Fidelity in Training
Instructions
Please limit your responses to information about .
Programs may be licensed and distributed by a third party rather than the initial developer/administrator,
and that is true of program-related training as well. In the following questions, please read “program
developer/administrator” as also referring to such third parties.
Terminology:
• Facilitators include staff members, volunteers, peers, or others who deliver program content to
participants. They may also be referred to by other names such as “leaders” or “coaches.”
• Trainers are staff members who instruct facilitators on how to faithfully deliver program content to
participants.
• Program trainers includes those identified as Master trainers or who have participated in a Train
the Trainer or similar program, certifying that they are able to instruct and/or mentor trainers in
the education of program facilitators. Program trainers may perform the role of facilitators as well.
We are now going to ask you some questions about how facilitators are trained.
16. Who is primarily responsible for training facilitators?
a. External—Program developer/administrator or training entity
b. Internal—Program-certified trainers on staff (if applicable)
c. Internal—Other staff members with program experience (e.g., facilitators)
d. Other (Please specify): __________________________________________________________
[If Question 16 = b or c, go to Question 17. All others skip to Question 18.]
17. What is the source of guidelines and materials used in training facilitators? (Check all that apply)
a. Program developer/administrator
b. Own organization
c. Peer organizations
d. State agency other than own organization
e. Other
18. In your experience, how clear are the guidelines for training facilitators provided by the program
developer/administrator?
a. Very clear
b. Somewhat clear
c. Somewhat unclear
d. Very unclear
e. No guidelines for training

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19. For programs that require certification for facilitators, when do you confirm that certifications are
current? (Check all that apply)
a. During grant application/approval process
b. When first offer program
c. Each time program is offered
d. Annually or regularly
e. We do not track this [If e is selected, no other responses should be selected.]
20. How are facilitators’ fidelity skills assessed after training is completed? (Check all that apply)
a. Formal observation of group/workshop sessions
b. Formal tests of skills or knowledge
c. Collection of feedback from participants or trainees
d. By monitoring process metrics to identify potential issues
e. Other (Please specify): __________________________________________________________
f. No assessment system in place [If f is selected, no other responses should be selected.]
21. What actions are taken if facilitators are found to be delivering content that does not meet program
guidelines? (Check all that apply)
a. Provide coaching
b. Create a corrective action plan
c. Issue a warning
d. Replacement
e. Other (Please specify): __________________________________________________________
f. None of the above [If f is selected, no other responses should be selected.]
22. What actions are taken if facilitators are found to be delivering the program in ways that do not meet
program guidelines (e.g., changing the order or length of sessions, making unauthorized program
adaptations)? (Check all that apply)
a. Provide coaching
b. Create a corrective action plan
c. Issue a warning
d. Replacement
e. Other (Please specify): __________________________________________________________

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We are now going to ask you some questions about how your program trainers are trained.
23. Who is primarily responsible for training program trainers?
a. External—Program developer/administrator or training entity
b. Internal—Program-certified trainers on staff (if applicable)
c. Internal—Other staff members with program experience
d. Other (Please specify): __________________________________________________________
[If Question 23 = b or c, answer Question 24. All others skip to Question 25.]
24. What is the source of guidelines and materials used in training program trainers? (Check all that apply)
a. Program developer/administrator
b. Own organization
c. Peer organizations
d. State agency other than own organization
e. Organization providing funding
25. For programs that require certification for program trainers, when do you confirm that certifications are
current? (Check all that apply)
a. During grant application/approval process
b. Each time program is offered
c. Annually or periodically
d. We do not track this [If d is selected, no other responses should be selected.]
26. How are program trainers assessed for fidelity practices after training is completed? (Check all that
apply)
a. Formal observation of group/workshop sessions
b. Formal tests of skills or knowledge
c. Collection of feedback from participants or trainees
d. By monitoring program metrics to identify potential issues
e. Other (please specify): __________________________________________________________
f. No assessment system in place [If f is selected, no other responses should be selected.]

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Fidelity in Program Resources
Instructions
In this section, “resources” refer to funding, staffing, equipment, and facilities. Other types of resources
may also be required for faithful implementation of some EBPs.
27. In your experience, how clear are the guidelines for program resources provided by the program
developer/administrator?
a. Very clear
b. Somewhat clear
c. Somewhat unclear
d. Very unclear
e. No guidelines for program resources
28. For each of the following, do the resources available for meet program
guidelines?
Please indicate for each of the factors whether resources are: 1 = Not adequate to meet guidelines,
2 = Adequate to meet guidelines, 3 = More than necessary to meet guidelines, or 4 = There are no
guidelines.
a. Funding
b. Staffing
c. Equipment
d. Facilities
29. How much of a challenge is it to meet program resource guidelines or requirements for the following
because of COST?
Please select among the following: 1 = No Challenge, 2 = Moderate Challenge, 3 = Extreme
Challenge, 4 = There are no guidelines
a. Program licensing
b. Participant materials
c. Recommended staffing level
d. Recommended staffing credentials
e. Recommended minimum space and/or accessibility
f. Recommended general equipment (chairs, tables, weights)
g. Recommended program-specific equipment or supplies
h. Recommended administrative personnel or equipment (e.g. data entry systems)
i. Other
30. How much of a challenge is it to meet program resource guidelines or requirements for the following
NON-COST reasons?
Please select among the following: 1 = No Challenge, 2 = Moderate Challenge, 3 = Extreme
Challenge, 4 = There are no guidelines
a. Program Licensing
b. Participant materials
c. Recommended staffing level
d. Recommended staffing credentials
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e.
f.
g.
h.
i.

Recommended minimum space and/or accessibility
Recommended general equipment (chairs, tables, weights)
Recommended program-specific equipment or supplies
Recommended administrative personnel or equipment (e.g. data entry systems)
Other

Fidelity in Target Population
Instructions
In this section, target population is the group the program was intended for, as specified in the model for
. These may be very general, such as “older adults,” or more specific, such as
“persons with arthritis or other chronic condition.”
31. In your experience, how clear are the guidelines for the target population provided by the program
developer/administrator?
a. Very clear
b. Somewhat clear
c. Somewhat unclear
d. Very unclear
e. No guidelines for target population
32. Do you permit participants who are not strictly within the target population to participate in the
program?
a. Yes
b. No
[If Question 32 = a, answer Questions 33-36. All others skip to Question 37.]
33. If enrollment is not restricted to targeted populations, approximately what percentage of the program
population is comprised of the target populations?
a. 75 to 100%
b. 50 to 74%
c. 25 to 49%
d. Under 25%
34. What adaptations, if any, have been made with respect to the population served? (Check all that apply)
a. Expanded to populations with different health conditions
b. Expanded to different ages
c. Expanded to include companions/caretakers
d. Other (please specify):___________________________________________________________

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[If Question 34 = a-c, answer Question 35. All others skip to Question 36.]
35. Why has the population been enlarged beyond the target population defined by the program
developer/administrator? (Check all that apply)
a. Target population not large enough to sustain program
b. Funding sources other than ACL require inclusion of other populations
c. Identified other populations that would benefit from the program
d. At the request of individuals or groups outside the target population
e. Other (please specify):___________________________________________________________
36. How do you verify that potential participants fall in the target population? (Check all that apply)
a. Referral from trusted organization
b. Self-identification
c. Require some form of documentation
d. Other (Please specify):__________________________________________________________

Fidelity in Content Provision
Instructions
When responding to the following questions, please focus on .
37. In your experience, how clear are the guidelines for content provided by the program
developer/administrator?
a. Very clear
b. Somewhat clear
c. Somewhat unclear
d. Very unclear
e. No guidelines for content
38. How often are all key components of the program content provided per the guidelines of the EBP?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this.
[If Question 38 = b-d, answer Question 39. All others skip to Question 40.]
39. Please describe the kind of adaptations made to components of the program content. (Check all that
apply)
a. Added new content
b. Dropped some original content
c. Modified some original content
d. Other (Please specify):__________________________________________________________
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40. How often are materials prescribed by guidelines (e.g., exercise bands, handouts, web pages, videos)
provided to participants according to the EBP guidelines?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this
[If Question 40 = b-d, answer Question 41. All others skip to Question 42.]
41. Please describe the kind of adaptations made to program materials. (Check all that apply)
a. Added new materials
b. Dropped some original materials
c. Modified some original materials
d. Other (Please specify):__________________________________________________________
42. How often is the content delivery mode (e.g., in-person vs. remote, lecture, discussion) prescribed by
the guidelines of the EBP followed?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this
[If Question 42 = b-d, answer Question 43. All others skip to answer Question 44]
43. Please describe the kind of adaptations made to content delivery mode. (Check all that apply)
a. Increased/decreased extent of remote content delivery
b. Increased/decreased extent of group discussions
c. Increased/decreased extent of group exercise
d. Other (Please specify):__________________________________________________________
44. How often is the frequency of sessions prescribed by the guidelines of the EBP followed?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this

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[If Question 44 = b-d, answer Question 45. All others skip to Question 46.]
45. Please describe the kind of adaptations made to the frequency of sessions. (Check all that apply)
a. More frequent
b. Less frequent
c. Other (Please specify):__________________________________________________________
46. How often is the length of sessions prescribed by the guidelines of the EBP followed?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this
[If Question 46 = b-d, answer Question 47. All others skip to Question 48.]
47. Please describe the kind of adaptations made to the length of sessions. (Check all that apply)
a. Longer
b. Shorter
c. Other (Please specify):__________________________________________________________
48. How often are the resource allocations (e.g., appropriately credentialed staff, equipment, locations)
prescribed by the guidelines of the EBP followed?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this
[If Question 48 = b-d, answer Question 49. All others skip to Question 50.]
49. Please describe the kind of adaptations made to resource allocations (e.g., staff, equipment, locations).
(Check all that apply)
a. Fewer staff per participant
b. Relaxation of staff credential/training requirements
c. Substitution/omission of certain types of equipment
d. Other (Please specify):__________________________________________________________

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50. How often is the group/session size within the limits (minimum and maximum) prescribed by the
guidelines of the EBP?
a. Always
b. Usually
c. Sometimes
d. Never
e. No relevant program guidelines
f. We do not track this
[If Question 50 = b-d, answer Question 51. All others skip to Question 52.]
51. Please describe the kind of adaptations made to group/session size.
a. Permit group/session smaller than prescribed minimum
b. Permit group/session larger than prescribed maximum
c. Other (Please specify):__________________________________________________________

Section 4. Program Adaptations
Adaptations NOT related to the Coronavirus Disease 2019 (COVID-19)
Public Health Emergency (PHE)
Instructions
We are interested in knowing whether you have made any adaptations to the program model for
, and if so, how that might impact fidelity. ACL requests that each question be
answered by someone with a good working knowledge of the topic at hand to ensure that the information
you supply is complete and accurate. For sections where someone else’s input would be most appropriate,
please enlist their assistance.
In this section, “adaptations” are intentional deviations from the program model and recommended
program guidelines.
NOTE: Please do NOT consider adaptations made to address the COVID-19 PHE when answering these
questions.
When responding to the following questions, please focus on .

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52. What factors does your organization consider when determining the need for adaptations to
? (Check all that apply)
a. Funding constraints
b. Availability of staff needed for guideline adherence
c. Availability of other resources needed for guideline adherence (e.g., facilities, equipment)
d. Accommodations for accessibility (disabilities, etc.)
e. Accommodations for lower-income and rural participants (transportation, hours, etc.)
f. Cultural inclusivity, including language and religion
g. To increase appeal to local populations
h. Other (Please specify):__________________________________________________________
i. Have not considered adaptations [If i is selected, no other responses should be selected.]
53. Whose input is important in determining whether to make adaptations and how they should be made?
(Check all that apply)
a. Program developer/administrator
b. Program participants
c. Partner organizations
d. Peer organizations
e. Local government, civic organizations, social, and/or religious organizations
f. State government
g. Funders
h. Other
i. Minimal/no external input
j. Do not make such determinations [If j is selected, no other responses should be selected.]
54. Has your organization worked with the program developer/administrator to identify acceptable program
adaptations that maintain the integrity of the evidence-based nature of the program?
a. Yes
b. No
[If Question 54= a, answer Question 55. All others skip to Question 56.]
55. If you have received guidance on adaptations for from the program
developer/administrator, when was it provided?
a. Program developer/administrator proactively provided guidance on adaptations
b. Provided in response to request for guidance
c. Did not provide guidance on adaptations
[Answer Question 56 if the implementation organization is a subcontractor/subgrantee/partner; All others
skip to Question 57]
56. If you have received guidance on adaptions from the source of your ACL funding, , when was it provided?
a. General guidance on adaptations allowed/recommended
b. Guidance only in response to specific requests for advice
c. No guidance provided

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Adaptations related to the COVID-19 PHE
Instructions
NOTE: The following section relates to changes in your operation of ACL-funded evidence-based
programs made in response to the COVID-19 PHE.
57. Prior to the COVID-19 PHE, what proportion of was provided in person?
a. All in person
b. Most in person, some remote
c. Some in person, most remote
d. All remote
e. Not sure
58. During the COVID-19 PHE, what proportion of content was provided inperson?
a. All in person
b. Most in person, some remote
c. Some in person, most remote
d. All remote
e. This program has been halted during the COVID-19 PHE
59. Which of the following program components have been modified in response to the COVID-19 PHE?
(Check all that apply)
a. Program Content
b. Materials (e.g., exercise bands, handouts, web pages, videos)
c. Delivery mode (e.g., in-person vs. remote, lecture, discussion)
d. Frequency of sessions
e. Duration of sessions
f. Resources allocated (e.g., staff, equipment, locations)
g. Group/session size (including number of clients per facilitator)
h. Other (Please specify):__________________________________________________________
60. What topics, if any, have you sought guidance on related to the COVID-19 PHE? (Check all that apply)
a. Safe in-person service delivery
b. How to redesign a program for remote delivery
c. Additional training needed for remote delivery
d. How to ensure that clients practiced the program safely without direct oversight
e. How to reach clients and recruit them for remote delivery
f. Other (Please specify):__________________________________________________________
g. Have not sought guidance on COVID-related adaptations [If g is selected, no other responses
should be selected.]

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61. Who provided guidance and other materials that helped you to adapt programs successfully during the
COVID-19 PHE? (Check all that apply)
a. Program developers
b. NCOA
c. Peer organizations
d. Participants and other stakeholders
e. CDC and other public health agencies
f. Other (Please specify):__________________________________________________________
g. No guidance received [If g is selected, no other responses should be selected.]
62. Has your funding decreased during the COVID-19 PHE for reasons other than
decreased demand for services?
a. Yes
b. No

Section 5. Support from ACL
Instructions
ACL requests that each question be answered by someone with a good working knowledge of the topic at
hand to ensure that the information you supply is complete and accurate. For sections where someone
else’s input would be most appropriate, please enlist their assistance.
63. In what ways could the selection of available EBPs be improved? (Check all that apply)
a. Update more frequently with newer programs
b. Increase the number of EBPs that are easy to implement as designed
c. Increase the number of EBPs that address other aspects of Falls or CDSME
d. Increase the number of EBPs in languages other than English
e. Increase the number of EBPs that have been tested with additional populations (members of
racial and ethnic minority groups, individuals with disabilities, etc.)
f. Increase the number of EBPs that can be delivered remotely
g. Other (Please specify) :__________________________________________________________
h. None [If h is selected, no other responses should be selected.]
64. What types of support would improve your organization’s ability to implement programs with fidelity
and/or maintain fidelity over time? (Check all that apply)
a. Assistance with selecting EBPs appropriate to your local context
b. Guidance on how to make local adaptations without threatening fidelity
c. Guidance and tools for effective monitoring of program implementations
d. Guidance and tools for maintaining fidelity over time
e. Guidance on controlling costs while maintaining fidelity
f. Assistance with evaluating the evidence base for EBPs
g. Other types of technical assistance regarding EBP programs
h. Other
i. No additional support required [If i is selected, no other responses should be selected.]

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[If Question 64 = a-h, answer Question 65. All others have completed the survey]
65. If you believe that any additional support would improve your organization’s ability to implement
programs with fidelity and/or maintain fidelity over time, please elaborate on your response.
[PROVIDE RESPONSE HERE]:

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection
of information unless such collection displays a valid OMB control number (OMB 0985-New). Public
reporting burden for this collection of information is estimated to average 30-40 minutes per response,
including time for gathering and maintaining the data needed and completing and reviewing the
collection of information. The obligation to respond to this collection is voluntary under the statutory
authority the Older Americans Act.

Conclusion
Thank you for participating in this survey!
Your responses will help ACL determine how to improve its grant-making process and its support and monitoring
of EBP fidelity, ensuring high quality delivery of proven programs to individuals and families supported by the
OOA.
If you have questions about this survey please contact Landry Nyandamu, HSAG, Associate Manager,
[email protected], 602-801-6801.

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