[NCHHSTP] _Expanding PrEP in Communities of Color (EPICC) (24BY)

ICR 202401-0920-004

OMB: 0920-1423

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-1423 can be found here:

2025-09-22 - No material or nonsubstantive change to a currently approved collection
2024-12-23 - No material or nonsubstantive change to a currently approved collection

Forms and Documents

Document Name	Status
Form 0920-22GA Aims 1&2 Clinic Assessment (every 6 months) Form and Instruction	Unchanged
Form 0920-22GA Aims 1&2 Clinic Assessment (Baseline & Final) Form and Instruction	Unchanged
Form 0920-22GA Aim 2b Provider Focus Group Guide Form and Instruction	Unchanged
Form 0920-22GA Aim 2b Provider Pre-Focus Group Survey Form and Instruction	Unchanged
Form 0920-22GA Aim 2b Provider Focus Group Contact Information Form and Instruction	Unchanged
Form 0920-22GA Aim 2b Provider Focus Group Screener Form and Instruction	Unchanged
Form 0920-22GA Aim 2a Cohort Exit Interview (English/Spanish) Form and Instruction	Unchanged
Form 0920-22GA Aim 2a Cohort Blood Collection Instructions (English/Spanish) Form and Instruction	Unchanged
Form 0920-22GA Aim 2a Cohort App Setup (English/Spanish) Form and Instruction	Unchanged
Form MOD00003217 Aim 2a Cohort Follow Up Survey (English/Spanish) Form and Instruction	Modified
Form 0920-22GA Aim 2a Cohort Baseline Survey (English/Spanish) Form and Instruction	Unchanged
Form 0920-22GA Aim 2a Cohort HIPAA Form (English & Spanish) Form and Instruction	Unchanged
Form 0920-22GA Aim 2a Cohort Contact Information (English/Spanish) Form and Instruction	Unchanged
Form MOD00003217 Aim 2a Cohort Screener (English/Spanish) Form and Instruction	Modified
Form 0920-22GA Aim 1 Provider Patient Interaction (Baseline and Final) Form and Instruction	Unchanged
Form 0920-22GA Aim 1 Provider Post-Training Survey Form and Instruction	Unchanged
Form MOD00003217 Aim 1 Provider Pre- Training Survey Form and Instruction	Modified
Form 0920-22GA Aim 1 Provider Training Contact Information Form and Instruction	Unchanged
Form 0920-22GA Aim 1 Provider Training Screener Form and Instruction	Unchanged
Justification for Nonmaterial Nonsubstantive Change to an OMB Approved Information Collection.docx Justification for No Material/Nonsubstantive Change	2024-01-05
Att 10_Summary of Changes Table (24BY).docx Supplementary Document	2024-01-05
Att_6l_Wake_County_Health_Department_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6k_Baylor_Harris_Health_PrEP_Clinic_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6j_Bliss_Healthcare_Services_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6i_USF_Ybor_Youth_Clinic_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6h_Five_Horizons_Health_Services_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6g_Amity_Medical_Group_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6f_Childrens_Hospital_of_Philadelphia_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6e_Childrens_Hospital_Montefiore_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6d_Cook_County_HHS_IRB_agreement[1].pdf Supplementary Document	2023-10-31
Att_6b_University_of_North_Carolina_Chapel_Hill_IRB_agreement[1].pdf Supplementary Document	2023-10-30
Att_6a_Florida_State_University_IRB_Letter_of_Approval[1].pdf Supplementary Document	2023-10-30
Att_9_Provider_Training_Summary[1].docx Supplementary Document	2023-10-30
Att_7_Data_Use_Plan_EPICC[1].docx Supplementary Document	2023-10-30
Att_1_Auth_Legislation[1].docx Supplementary Document	2023-10-30
30_Day_FRN_EPICC[1].docx Supplementary Document	2023-10-30
SSB[1].docx Supporting Statement B	2023-10-30
SSA.docx Supporting Statement A	2023-10-30

IC Document Collections

IC ID	Document Title	Status
263138	Aims 1&2 Clinic Assessment (every 6 months) Form and Instruction	Unchanged
263136	Aims 1&2 Clinic Assessment (Baseline & Final) Form and Instruction	Unchanged
263135	Aim 2b Provider Focus Group Guide Form and Instruction	Unchanged
263134	Aim 2b Provider Pre-Focus Group Survey Form and Instruction	Unchanged
263133	Aim 2b Provider Focus Group Contact Information Form and Instruction	Unchanged
263132	Aim 2b Provider Focus Group Screener Form and Instruction	Unchanged
263131	Aim 2a Cohort Exit Interview (English/Spanish) Form and Instruction	Unchanged
263130	Aim 2a Cohort Blood Collection Instructions (English/Spanish) Form and Instruction	Unchanged
263129	Aim 2a Cohort App Setup (English/Spanish) Form and Instruction	Unchanged
263128	Aim 2a Cohort Follow Up Survey (English/Spanish) Form and Instruction	Modified
263127	Aim 2a Cohort Baseline Survey (English/Spanish) Form and Instruction	Unchanged
263122	Aim 2a Cohort HIPAA Form (English & Spanish) Form and Instruction	Unchanged
263121	Aim 2a Cohort Contact Information (English/Spanish) Form and Instruction	Unchanged
263120	Aim 2a Cohort Screener (English/Spanish) Form and Instruction	Modified
263118	Aim 1 Provider Patient Interaction (Baseline and Final) Form and Instruction	Unchanged
263117	Aim 1 Provider Post-Training Survey Form and Instruction	Unchanged
263116	Aim 1 Provider Pre- Training Survey Form and Instruction	Modified
263115	Aim 1 Provider Training Contact Information Form and Instruction	Unchanged
263114	Aim 1 Provider Training Screener Form and Instruction	Unchanged

ICR Details