[NCHHSTP] Expanding PrEP in Communities of Color (EPICC)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-22GA Aims 1&2 Clinic Assessment (every 6 months)	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Aims 1&2 Clinic Assessment (every 6 months)	Form and Instruction	Unchanged	Missing upstream
Form 0920-22GA Att 4r_Aim1&2ClinicAssessmentBaselineAndFinal	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Aims 1&2 Clinic Assessment (Baseline & Final)	Form and Instruction	Unchanged	Repair queued
Form 0920-1423 Att 4q_Aim2b Provider Focus Group Guide _REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-22GA Att 4o_Aim2b Provider FocusGroup Contact Information	Form and Instruction	Modified	Available
Form 0920-22GA Aim 2b Provider Focus Group Guide	Form and Instruction	Modified	Repair queued
Form 0920-1423 Att 4p_Aim2b Provider Pre-Focus Group Survey _REV 19SEP2025	Form and Instruction	Modified	Repair queued
Form 0920-1423 Aim 2b Provider Pre-Focus Group Survey_23DEC2024	Form and Instruction	Modified	Available
Form 0920-22GA Att 4p_Aim2b Provider Pre FocusGroup Survey	Form and Instruction	Modified	Available
Form 0920-22GA Aim 2b Provider Pre-Focus Group Survey	Form and Instruction	Modified	Repair queued
Form 0920-22GA Att 4o_Aim2b Provider FocusGroup Contact Information	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 2b Provider Focus Group Contact Information	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Att_4n_Aim2bProvider FocusGroup Screener	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Aim 2b Provider Focus Group Screener	Form and Instruction	Unchanged	Repair queued
Form 0920-1423 Att 4m_Aim2a Cohort Exit Interview Spanish _REV 19SEP2025	Form and Instruction	Modified	Repair queued
Form 0920-1423 Att 4m_Aim2a Cohort Exit Interview English _REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-22GA Att 4m_Aim2aCohortExitInterviewSpanish	Form and Instruction	Modified	Repair queued
Form 0920-22GA Att 4m_Aim2a Cohort Exit Interview English	Form and Instruction	Modified	Repair queued
Form 0920-22GA Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-1423 Aim 2a Cohort Blood Collection Instructions_Spanish	Form and Instruction	Unchanged	Available
Form 0920-1423 Aim 2a Cohort Blood Collection Instructions_English	Form and Instruction	Unchanged	Available
Form 0920-22GA Att 4l_Aim2a Cohort Blood Collection Instructions English	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 2a Cohort Blood Collection Instructions (English/Spanish)	Form and Instruction	Unchanged	Repair queued
Form 0920-1423 Att 4j - Aim2a Cohort App Setup English-Spanish _REV 19SEP2025	Form and Instruction	Modified	Repair queued
Form 0920-22GA Att 4j_Aim2aCohortAppSetupEnglishSpanish	Form and Instruction	Modified	Available
Form 0920-22GA Aim 2a Cohort App Setup (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-1423 Att 4k - Aim2a Cohort Follow-up Survey Spanish_REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-1423 Att 4k - Aim2a Cohort Follow-up Survey English_REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-1423-24BY Encuesta de seguimiento de cohortes (Aim2aCohortFollowUpSurveySpanish)	Form and Instruction	Modified	Available
Form MOD00003217 Aim 2a Cohort Follow Up Survey English	Form and Instruction	Modified	Available
Form MOD00003217 Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-1423 Att 4i - Aim2a Cohort Baseline Survey Spanish_REV 19SEP2025	Form and Instruction	Modified	Repair queued
Form 0920-1423 Att 4i - Aim2a Cohort Baseline Survey English_REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-22GA Att 4i_Aim2aCohortBaselineSurveySpanish	Form and Instruction	Modified	Available
Form 0920-22GA Att 4i_Aim2aCohortBaselineSurveyEnglish	Form and Instruction	Modified	Available
Form 0920-22GA Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-22GA Att 4h_Aim2aCohortHIPAAFormSpanish	Form and Instruction	Unchanged	Available
Form 0920-22GA Att 4h_Aim2aCohortHIPAAFormEnglish	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 2a Cohort HIPAA Form (English & Spanish)	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Att 4b_Aim1ProviderTrainingContactInformation	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 2a Cohort Contact Information (English/Spanish)	Form and Instruction	Unchanged	Repair queued
Form 0920-1423 Att 4f - Aim2a Cohort Screener Spanish_REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-1423 Att 4f - Aim2a Cohort Screener English_REV 19SEP2025	Form and Instruction	Modified	Available
Form 0920-1423 Aim 2a - Cohort Screeeer_Spanish	Form and Instruction	Modified	Available
Form 0920-1423 Aim 2a - Cohort Screeeer_English	Form and Instruction	Modified	Available
Form V2023-1102 Elegibilidad de cohorte (Aim2aCohortScreener_Spanish)	Form and Instruction	Modified	Available
Form MOD00003217 Aim 2a Cohort Screener English	Form and Instruction	Modified	Available
Form MOD00003217 Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Repair queued
Form 0920-22GA Att 4e_Aim1ProviderPatientInteraction	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 1 Provider Patient Interaction (Baseline and Final)	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Att 4d_Aim1ProviderPostTrainingSurvey	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 1 Provider Post-Training Survey	Form and Instruction	Unchanged	Repair queued
Form MOD00003217 Aim 1 Provider Pre-Training Survey	Form and Instruction	Unchanged	Available
Form MOD00003217 Aim 1 Provider Pre- Training Survey	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Att 4b_Aim1ProviderTrainingContactInformation	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Aim 1 Provider Training Contact Information	Form and Instruction	Unchanged	Repair queued
Form 0920-22GA Att 4a_Aim1ProviderTrainingScreener	Form and Instruction	Unchanged	Available
Form 0920-22GA Aim 1 Provider Training Screener	Form and Instruction	Unchanged	Repair queued
Change Request Memo_EPICC.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-09-19	Available
Change Request Memo_EPICC.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-09-19	Repair queued
Att 5b_Consent_Spanish_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 5b_Consent_Spanish_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 5b_Consent_English_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 5b_Consent_English_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 3b_RecruitmentPlan_Spanish_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 3b_RecruitmentPlan_Spanish_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Att 3b_RecruitmentPlan_English_clean.docx	Supplementary Document	Uploaded 2025-09-19	Available
Att 3b_RecruitmentPlan_English_clean.docx	Supplementary Document	Uploaded 2025-09-19	Repair queued
Justification and Summary of Changes.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-12-23	Available
Justification and Summary of Changes.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-12-23	Repair queued
Justification for Nonmaterial Nonsubstantive Change to an OMB Approved Information Collection.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-05	Available
Justification for Nonmaterial Nonsubstantive Change to an OMB Approved Information Collection.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2024-01-05	Repair queued
Att 10_Summary of Changes Table (24BY).docx	Supplementary Document	Uploaded 2024-01-05	Available
Att 10_Summary of Changes Table (24BY).docx	Supplementary Document	Uploaded 2024-01-05	Available
Att_6l_Wake_County_Health_Department_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Available
Att_6l_Wake_County_Health_Department_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6k_Baylor_Harris_Health_PrEP_Clinic_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6k_Baylor_Harris_Health_PrEP_Clinic_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6j_Bliss_Healthcare_Services_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6j_Bliss_Healthcare_Services_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6i_USF_Ybor_Youth_Clinic_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Available
Att_6i_USF_Ybor_Youth_Clinic_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6h_Five_Horizons_Health_Services_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Available
Att_6h_Five_Horizons_Health_Services_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6g_Amity_Medical_Group_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6g_Amity_Medical_Group_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6f_Childrens_Hospital_of_Philadelphia_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6f_Childrens_Hospital_of_Philadelphia_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6e_Childrens_Hospital_Montefiore_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Available
Att_6e_Childrens_Hospital_Montefiore_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6d_Cook_County_HHS_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Available
Att_6d_Cook_County_HHS_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-31	Repair queued
Att_6b_University_of_North_Carolina_Chapel_Hill_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-30	Available
Att_6b_University_of_North_Carolina_Chapel_Hill_IRB_agreement[1].pdf	Supplementary Document	Uploaded 2023-10-30	Repair queued
Att_6a_Florida_State_University_IRB_Letter_of_Approval[1].pdf	Supplementary Document	Uploaded 2023-10-30	Available
Att_6a_Florida_State_University_IRB_Letter_of_Approval[1].pdf	Supplementary Document	Uploaded 2023-10-30	Repair queued
Att_9_Provider_Training_Summary[1].docx	Supplementary Document	Uploaded 2023-10-30	Available
Att_9_Provider_Training_Summary[1].docx	Supplementary Document	Uploaded 2023-10-30	Repair queued
Att_7_Data_Use_Plan_EPICC[1].docx	Supplementary Document	Uploaded 2023-10-30	Available
Att_7_Data_Use_Plan_EPICC[1].docx	Supplementary Document	Uploaded 2023-10-30	Repair queued
Att_1_Auth_Legislation[1].docx	Supplementary Document	Uploaded 2023-10-30	Available
Att_1_Auth_Legislation[1].docx	Supplementary Document	Uploaded 2023-10-30	Repair queued
30_Day_FRN_EPICC[1].docx	Supplementary Document	Uploaded 2023-10-30	Available
30_Day_FRN_EPICC[1].docx	Supplementary Document	Uploaded 2023-10-30	Repair queued
SSB_Clean.docx	Supporting Statement B	Uploaded 2025-09-19	Available
SSB_Clean.docx	Supporting Statement B	Uploaded 2025-09-19	Repair queued
SSA_Clean.docx	Supporting Statement A	Uploaded 2025-09-19	Repair queued
SSA_Clean.docx	Supporting Statement A	Uploaded 2025-09-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263138	Aims 1&2 Clinic Assessment (every 6 months)	Form and Instruction	Unchanged	Aims 1&2 Clinic Assessment (every 6 months)
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	Att 4r_Aim1&2ClinicAssessmentBaselineAndFinal
263136	Aims 1&2 Clinic Assessment (Baseline & Final)	Form and Instruction	Unchanged
263135	Aim 2b Provider Focus Group Guide	Form and Instruction	Modified	Att 4q_Aim2b Provider Focus Group Guide _REV 19SEP2025
263135	Aim 2b Provider Focus Group Guide	Form and Instruction	Modified	Att 4o_Aim2b Provider FocusGroup Contact Information
263135	Aim 2b Provider Focus Group Guide	Form and Instruction	Modified
263134	Aim 2b Provider Pre-Focus Group Survey	Form and Instruction	Modified	Att 4p_Aim2b Provider Pre-Focus Group Survey _REV 19SEP2025
263134	Aim 2b Provider Pre-Focus Group Survey	Form and Instruction	Modified	Aim 2b Provider Pre-Focus Group Survey_23DEC2024
263134	Aim 2b Provider Pre-Focus Group Survey	Form and Instruction	Modified	Att 4p_Aim2b Provider Pre FocusGroup Survey
263134	Aim 2b Provider Pre-Focus Group Survey	Form and Instruction	Modified
263133	Aim 2b Provider Focus Group Contact Information	Form and Instruction	Unchanged	Att 4o_Aim2b Provider FocusGroup Contact Information
263133	Aim 2b Provider Focus Group Contact Information	Form and Instruction	Unchanged
263132	Aim 2b Provider Focus Group Screener	Form and Instruction	Unchanged	Att_4n_Aim2bProvider FocusGroup Screener
263132	Aim 2b Provider Focus Group Screener	Form and Instruction	Unchanged
263131	Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified	Att 4m_Aim2a Cohort Exit Interview Spanish _REV 19SEP2025
263131	Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified	Att 4m_Aim2a Cohort Exit Interview English _REV 19SEP2025
263131	Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified	Att 4m_Aim2aCohortExitInterviewSpanish
263131	Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified	Att 4m_Aim2a Cohort Exit Interview English
263131	Aim 2a Cohort Exit Interview (English/Spanish)	Form and Instruction	Modified
263130	Aim 2a Cohort Blood Collection Instructions (English/Spanish)	Form and Instruction	Unchanged	Aim 2a Cohort Blood Collection Instructions_Spanish
263130	Aim 2a Cohort Blood Collection Instructions (English/Spanish)	Form and Instruction	Unchanged	Aim 2a Cohort Blood Collection Instructions_English
263130	Aim 2a Cohort Blood Collection Instructions (English/Spanish)	Form and Instruction	Unchanged	Att 4l_Aim2a Cohort Blood Collection Instructions English
263130	Aim 2a Cohort Blood Collection Instructions (English/Spanish)	Form and Instruction	Unchanged
263129	Aim 2a Cohort App Setup (English/Spanish)	Form and Instruction	Modified	Att 4j - Aim2a Cohort App Setup English-Spanish _REV 19SEP2025
263129	Aim 2a Cohort App Setup (English/Spanish)	Form and Instruction	Modified	Att 4j_Aim2aCohortAppSetupEnglishSpanish
263129	Aim 2a Cohort App Setup (English/Spanish)	Form and Instruction	Modified
263128	Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified	Att 4k - Aim2a Cohort Follow-up Survey Spanish_REV 19SEP2025
263128	Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified	Att 4k - Aim2a Cohort Follow-up Survey English_REV 19SEP2025
263128	Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified	Encuesta de seguimiento de cohortes (Aim2aCohortFollowUpSurveySpanish)
263128	Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified	Aim 2a Cohort Follow Up Survey English
263128	Aim 2a Cohort Follow Up Survey (English/Spanish)	Form and Instruction	Modified
263127	Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified	Att 4i - Aim2a Cohort Baseline Survey Spanish_REV 19SEP2025
263127	Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified	Att 4i - Aim2a Cohort Baseline Survey English_REV 19SEP2025
263127	Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified	Att 4i_Aim2aCohortBaselineSurveySpanish
263127	Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified	Att 4i_Aim2aCohortBaselineSurveyEnglish
263127	Aim 2a Cohort Baseline Survey (English/Spanish)	Form and Instruction	Modified
263122	Aim 2a Cohort HIPAA Form (English & Spanish)	Form and Instruction	Unchanged	Att 4h_Aim2aCohortHIPAAFormSpanish
263122	Aim 2a Cohort HIPAA Form (English & Spanish)	Form and Instruction	Unchanged	Att 4h_Aim2aCohortHIPAAFormEnglish
263122	Aim 2a Cohort HIPAA Form (English & Spanish)	Form and Instruction	Unchanged
263121	Aim 2a Cohort Contact Information (English/Spanish)	Form and Instruction	Unchanged	Att 4b_Aim1ProviderTrainingContactInformation
263121	Aim 2a Cohort Contact Information (English/Spanish)	Form and Instruction	Unchanged
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Att 4f - Aim2a Cohort Screener Spanish_REV 19SEP2025
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Att 4f - Aim2a Cohort Screener English_REV 19SEP2025
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Aim 2a - Cohort Screeeer_Spanish
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Aim 2a - Cohort Screeeer_English
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Elegibilidad de cohorte (Aim2aCohortScreener_Spanish)
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified	Aim 2a Cohort Screener English
263120	Aim 2a Cohort Screener (English/Spanish)	Form and Instruction	Modified
263118	Aim 1 Provider Patient Interaction (Baseline and Final)	Form and Instruction	Unchanged	Att 4e_Aim1ProviderPatientInteraction
263118	Aim 1 Provider Patient Interaction (Baseline and Final)	Form and Instruction	Unchanged
263117	Aim 1 Provider Post-Training Survey	Form and Instruction	Unchanged	Att 4d_Aim1ProviderPostTrainingSurvey
263117	Aim 1 Provider Post-Training Survey	Form and Instruction	Unchanged
263116	Aim 1 Provider Pre- Training Survey	Form and Instruction	Unchanged	Aim 1 Provider Pre-Training Survey
263116	Aim 1 Provider Pre- Training Survey	Form and Instruction	Unchanged
263115	Aim 1 Provider Training Contact Information	Form and Instruction	Unchanged	Att 4b_Aim1ProviderTrainingContactInformation
263115	Aim 1 Provider Training Contact Information	Form and Instruction	Unchanged
263114	Aim 1 Provider Training Screener	Form and Instruction	Unchanged	Att 4a_Aim1ProviderTrainingScreener
263114	Aim 1 Provider Training Screener	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0920-1423	ICR Reference No: 202509-0920-006
Status: Historical Active	Previous ICR Reference No: 202412-0920-015
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-25-0174
Title: [NCHHSTP] Expanding PrEP in Communities of Color (EPICC)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/23/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/22/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	12/31/2026	12/31/2026
Responses	1,244	0	1,244
Time Burden (Hours)	759	0	759
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this study is to implement and evaluate the effectiveness of a clinic-based intervention that utilizes evidence-based education and support tools to 1) increase provider knowledge of and comfort with HIV preexposure prophylaxis (PrEP) modalities in clinical practice and 2) improve PrEP adherence among young men and non-binary persons who have sex with men (YMSM). This Change Request is submitted to modify language to comply with EO 14168. There is no anticipated change to the approved burden.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: U.S. PHSA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 41623	06/27/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 62793	09/13/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 19

table that charts list of burden

IC Title	Form No.	Form Name
Aim 1 Provider Patient Interaction (Baseline and Final)	0920-22GA	Att 4e_Aim1ProviderPatientInteraction
Aim 1 Provider Post-Training Survey	0920-22GA	Att 4d_Aim1ProviderPostTrainingSurvey
Aim 1 Provider Pre- Training Survey	MOD00003217	Aim 1 Provider Pre-Training Survey
Aim 1 Provider Training Contact Information	0920-22GA	Att 4b_Aim1ProviderTrainingContactInformation
Aim 1 Provider Training Screener	0920-22GA	Att 4a_Aim1ProviderTrainingScreener
Aim 2a Cohort App Setup (English/Spanish)	0920-1423, 0920-22GA	Att 4j_Aim2aCohortAppSetupEnglishSpanish ,   Att 4j - Aim2a Cohort App Setup English-Spanish _REV 19SEP2025
Aim 2a Cohort Baseline Survey (English/Spanish)	0920-22GA, 0920-22GA, 0920-1423, 0920-1423	Att 4i_Aim2aCohortBaselineSurveyEnglish ,   Att 4i_Aim2aCohortBaselineSurveySpanish ,   Att 4i - Aim2a Cohort Baseline Survey English_REV 19SEP2025 ,   Att 4i - Aim2a Cohort Baseline Survey Spanish_REV 19SEP2025
Aim 2a Cohort Blood Collection Instructions (English/Spanish)	0920-22GA, 0920-1423, 0920-1423	Att 4l_Aim2a Cohort Blood Collection Instructions English ,   Aim 2a Cohort Blood Collection Instructions_English ,   Aim 2a Cohort Blood Collection Instructions_Spanish
Aim 2a Cohort Contact Information (English/Spanish)	0920-22GA	Att 4b_Aim1ProviderTrainingContactInformation
Aim 2a Cohort Exit Interview (English/Spanish)	0920-22GA, 0920-22GA, 0920-1423, 0920-1423	Att 4m_Aim2a Cohort Exit Interview English ,   Att 4m_Aim2aCohortExitInterviewSpanish ,   Att 4m_Aim2a Cohort Exit Interview English _REV 19SEP2025 ,   Att 4m_Aim2a Cohort Exit Interview Spanish _REV 19SEP2025
Aim 2a Cohort Follow Up Survey (English/Spanish)	0920-1423-24BY, MOD00003217, 0920-1423, 0920-1423	Aim 2a Cohort Follow Up Survey English ,   Encuesta de seguimiento de cohortes (Aim2aCohortFollowUpSurveySpanish) ,   Att 4k - Aim2a Cohort Follow-up Survey English_REV 19SEP2025 ,   Att 4k - Aim2a Cohort Follow-up Survey Spanish_REV 19SEP2025
Aim 2a Cohort HIPAA Form (English & Spanish)	0920-22GA, 0920-22GA	Att 4h_Aim2aCohortHIPAAFormEnglish ,   Att 4h_Aim2aCohortHIPAAFormSpanish
Aim 2a Cohort Screener (English/Spanish)	MOD00003217, V2023-1102, 0920-1423, 0920-1423, 0920-1423, 0920-1423	Aim 2a Cohort Screener English ,   Elegibilidad de cohorte (Aim2aCohortScreener_Spanish) ,   Aim 2a - Cohort Screeeer_English ,   Aim 2a - Cohort Screeeer_Spanish ,   Att 4f - Aim2a Cohort Screener English_REV 19SEP2025 ,   Att 4f - Aim2a Cohort Screener Spanish_REV 19SEP2025
Aim 2b Provider Focus Group Contact Information	0920-22GA	Att 4o_Aim2b Provider FocusGroup Contact Information
Aim 2b Provider Focus Group Guide	0920-1423, 0920-22GA	Att 4o_Aim2b Provider FocusGroup Contact Information ,   Att 4q_Aim2b Provider Focus Group Guide _REV 19SEP2025
Aim 2b Provider Focus Group Screener	0920-22GA	Att_4n_Aim2bProvider FocusGroup Screener
Aim 2b Provider Pre-Focus Group Survey	0920-22GA, 0920-1423, 0920-1423	Att 4p_Aim2b Provider Pre FocusGroup Survey ,   Aim 2b Provider Pre-Focus Group Survey_23DEC2024 ,   Att 4p_Aim2b Provider Pre-Focus Group Survey _REV 19SEP2025
Aims 1&2 Clinic Assessment (Baseline & Final)	0920-22GA	Att 4r_Aim1&2ClinicAssessmentBaselineAndFinal
Aims 1&2 Clinic Assessment (every 6 months)	0920-22GA	Aims 1&2 Clinic Assessment (every 6 months)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,244	1,244	0	0	0	0
Annual Time Burden (Hours)	759	759	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,112,799

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/22/2025

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