[NCHHSTP] mChoice: Improving PrEP Uptake and Adherence among Minority MSM through Tailored Provider Training and Adherence Assistance in Two High Priority Settings

ICR 202402-0920-005

OMB: 0920-1428

Federal Form Document

Forms and Documents

Document Name	Status
Form 0920-22FZ Clinic Assessment Every Six Months Form and Instruction	Unchanged
Form 0920-22FZ Clinical Assesment Baseline & Final Form and Instruction	Unchanged
Form 0920-22FZ Provider Interview Form and Instruction	Unchanged
Form 0920-22FZ Provider Post-Training Assessment Form and Instruction	Unchanged
Provider Pre-Training Assessment Form and Instruction	Modified
Form 0920-22FZ Provider Locator Form Form and Instruction	Unchanged
Form 0920-22FZ Provider Screening Form and Instruction	Unchanged
Form 0920-22FZ Patient Interview Guide Form and Instruction	Unchanged
CleverCap App Setup Form and Instruction	Modified
Patient Quarterly Assessment Form and Instruction	Modified
Patient Baseline Form and Instruction	Modified
Form 0920-22FZ Patient Locator Form Form and Instruction	Unchanged
Patient Screener (English/Spanish) Form and Instruction	Modified
mChoice_summary of changes memo_011024.docx Justification for No Material/Nonsubstantive Change	2024-02-14
Att 9_Provider Training Summary.docx Supplementary Document	2024-02-14
Att 8_Privacy Impact Assessment_mChoice.pdf Supplementary Document	2024-02-14
Att 7_Data Use Plan mChoice.docx Supplementary Document	2024-02-14
Att 6d_Callen_Lorde IRB reliance agreement.pdf Supplementary Document	2024-02-14
Att 6b_University of Alabama at Birmingham IRB reliance agreement.pdf Supplementary Document	2024-02-14
Att 6a_Columbia University IRB approval.pdf Supplementary Document	2024-02-14
Att 5e_Provider Consent Form.pdf Supplementary Document	2024-02-14
Att 5d_Provider Consent to Screen.pdf Supplementary Document	2024-02-14
Att 5c_Patient Interview Consent Form Spanish.pdf Supplementary Document	2024-02-14
Att 5c_Patient Interview Consent Form English.pdf Supplementary Document	2024-02-14
Att 5b_Patient Consent Form Spanish.pdf Supplementary Document	2024-02-14
Att 5b_Patient Consent Form English.pdf Supplementary Document	2024-02-14
Att 5a_Patient Consent to Screen Spanish.pdf Supplementary Document	2024-02-14
Att 5a_Patient Consent to Screen_CLEAN.pdf Supplementary Document	2024-02-14
Att 3b_Provider Recruitment Materials.docx Supplementary Document	2024-02-14
Att 3a_Patient Recruitment Materials Spanish.docx Supplementary Document	2024-02-14
Att 3a_Patient Recruitment Materials English.docx Supplementary Document	2024-02-14
Att 2a_60-day FRN Pub 6_13_2022.pdf Supplementary Document	2024-02-14
Att 1_Auth Legislation.docx Supplementary Document	2023-11-15
SSB mChoice.docx Supporting Statement B	2023-11-15
SSA_mChoice.docx Supporting Statement A	2023-11-15

IC Document Collections

IC ID	Document Title	Status
263498	Clinic Assessment Every Six Months Form and Instruction	Unchanged
263497	Clinical Assesment Baseline & Final Form and Instruction	Unchanged
263496	Provider Interview Form and Instruction	Unchanged
263495	Provider Post-Training Assessment Form and Instruction	Unchanged
263494	Provider Pre-Training Assessment Form and Instruction	Modified
263493	Provider Locator Form Form and Instruction	Unchanged
263492	Provider Screening Form and Instruction	Unchanged
263491	Patient Interview Guide Form and Instruction	Unchanged
263490	CleverCap App Setup Form and Instruction	Modified
263489	Patient Quarterly Assessment Form and Instruction	Modified
263488	Patient Baseline Form and Instruction	Modified
263487	Patient Locator Form Form and Instruction	Unchanged
263486	Patient Screener (English/Spanish) Form and Instruction	Modified