Information Collection

Fidelity Evaluation of the Administration for Community Livings Evidence-Based Programs

IC 250380 under ICR 202111-0985-003 · OMB 0985-0073.

Documents and Forms

Document Name Document Type
Fidelity Evaluation of the Administration for Community Livings Evidence-Based Programs Form and Instruction
Fidelity Evaluation-Grantee Survey 0985-New Fidelity Grantee Survey Fin.pdf Form and Instruction
Fidelity Evaluation-Grantee Survey 0985-New Fidelity Grantee Survey Fin.pdf Form and Instruction
Fidelity Evaluation-Site Survey 0985-New Fidelity Site Survey Fin.pdf Form and Instruction
Fidelity Evaluation-Site Survey 0985-New Fidelity Site Survey Fin.pdf Form and Instruction
0985-New IC Supplemental EB Invitation.docx Fidelity Evidence-Based Email Invitation IC Document
0985-New IC Supplemental EB Announcement.docx Fidelity Evidence-Based Announcement IC Document
0985-New IC Supplemental EB Reminders.docx Fidelity Evidence-Based Reminders IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Fidelity Evaluation of the Administration for Community Livings Evidence-Based Programs	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
Form and Instruction	NA	Fidelity Evaluation-Grantee Survey	0985-New Fidelity Grantee Survey Fin.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	NA	Fidelity Evaluation-Site Survey	0985-New Fidelity Site Survey Fin.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 515	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	515	515
Annual IC Time Burden (Hours)	445	445
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Fidelity Evidence-Based Email Invitation	0985-New IC Supplemental EB Invitation.docx	01/21/2022
Fidelity Evidence-Based Announcement	0985-New IC Supplemental EB Announcement.docx	01/21/2022
Fidelity Evidence-Based Reminders	0985-New IC Supplemental EB Reminders.docx	01/21/2022

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