Form 0920-22GA Att 4a_Aim1ProviderTrainingScreener

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

Expanding PrEP in Communities of Color (EPICC+)

Attachment 4a

Aim 1 Provider Training Screener

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Provider Training Screener

1. Does the participant provide PrEP services to YMSM at a participating clinic site?

   • Yes

   • No

[If no to above question, participant ineligible and display text: This provider is ineligible for this study. Thank them for their time and do not complete any additional enrollment procedures]

2. Is the participant a staff member at a participating clinical site?

   • Yes

   • No

[If no to above question, participant ineligible and display text: This provider is ineligible for this study. Thank them for their time and do not complete any additional enrollment procedures]

[If yes to both inclusion and exclusion criteria display the text below]

This provider is eligible to participate in provider training.

3. Does this provider have prescribing privileges?

   • Yes

   • No

[If no, review provider training tracking log to ensure that no more than 50% of the sample is unable to prescribe PrEP]