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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.