IIE Adherence Form IIE Adherence Form

40170, RPG Adherence Data Form

Mathematica Policy Research

Adherence Data Form
Regional Partnership Grants (RPG) Program Evaluation
Instructions: The adherence data form is designed to document grantee performance indicators needed to calculate an adherence score for each
focal evidence-based program (EBP). The adherence score quantifies the progress each grantee has made toward implementing the focal EBP. The
adherence score is calculated by completing the table below two times a year beginning in April 2014 for each focal EBP implemented by a grantee.
Each administration covers the prior six-month period and will take the individual assigned to complete the form approximately 1.5 hours.
Adherence forms should be submitted with grantees’ Semiannual Progress Reports. When submitting the adherence form, the “Staff ID” column
should be removed to ensure confidentiality, but the grantee should keep a copy of the form with the “Staff ID” column for their records.
Grantee:
Evidence-Based Program (EBP):
Total number of frontline positions allocated to the EBP:
Number of allocated positions that are vacant:
Number of frontline staff in position as of MM/DD/YYYY:

Position
Number

Caseworker 1
Caseworker 2
Caseworker 3

Staff ID
(remove before
sending to
Mathematica)

A staff
person is in
the position.
No=0
Yes=1

The staff
person has
received initial
training.
No=0
Yes=1

Ongoing support
(coaching,
supervision, and/or
technical assistance)
has been provided
as prescribed.
No=0
Yes=1

Performance
Assessment
Criteria Met at
the Last
Assessment.
No=0
Yes=1

Performance
Assessment
Criteria Met at
the Last Two
Assessments.
No=0
Yes=1

Total
Position
Score
(Maximum
Score=5

Adherence Score (sum of position scores/number of positions):

DRAFT N:\Transfer\HShah\Final_Nov_2013\OMB Attachments to CB November 2013\IIE Adherence Form.docx 1

11/25/13 12:40 PM