OMB control number

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

OMB 0920-1423 · HHS/CDC.

OMB 0920-1423

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 make minor edits to a few instruments and supporting statements.

The latest form for [NCHHSTP] Expanding PrEP in Communities of Color (EPICC) expires 2026-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Aims 1&2 Clinic Assessment (every 6 months) Form and Instruction
Aims 1&2 Clinic Assessment (Baseline & Final) Form and Instruction
Form 0920-22GA Aim 2b Provider Focus Group Guide Form and Instruction
Form 0920-22GA Aim 2b Provider Pre-Focus Group Survey Form and Instruction
Form 0920-22GA Aim 2b Provider Focus Group Contact Information Form and Instruction
Form 0920-22GA Aim 2b Provider Focus Group Screener Form and Instruction
Form 0920-22GA Aim 2a Cohort Exit Interview (English/Spanish) Form and Instruction
Form 0920-22GA Aim 2a Cohort Blood Collection Instructions (English/Spanish) Form and Instruction
Form 0920-22GA Aim 2a Cohort App Setup (English/Spanish) Form and Instruction
Aim 2a Cohort Follow Up Survey (English/Spanish) Form and Instruction
Aim 2a Cohort Baseline Survey (English/Spanish) Form and Instruction
Form 0920-22GA Aim 2a Cohort HIPAA Form (English & Spanish) Form and Instruction
Form 0920-22GA Aim 2a Cohort Contact Information (English/Spanish) Form and Instruction
Form MOD00003217 Aim 2a Cohort Screener (English/Spanish) Form and Instruction
Form 0920-22GA Aim 1 Provider Patient Interaction (Baseline and Final) Form and Instruction
Form 0920-22GA Aim 1 Provider Post-Training Survey Form and Instruction
Form MOD00003217 Aim 1 Provider Pre- Training Survey Form and Instruction
Form 0920-22GA Aim 1 Provider Training Contact Information Form and Instruction
Form 0920-22GA Aim 1 Provider Training Screener Form and Instruction
EPICC Justification and Summary of Changes.docx Justification for No Material/Nonsubstantive Change
Change Request Memo_EPICC.docx Justification for No Material/Nonsubstantive Change
Att 5b_Consent_Spanish_clean.docx Supplementary Document
Att 5b_Consent_English_clean.docx Supplementary Document
Att 3b_RecruitmentPlan_Spanish_clean.docx Supplementary Document
Att 3b_RecruitmentPlan_English_clean.docx Supplementary Document
Justification and Summary of Changes.docx Justification for No Material/Nonsubstantive Change
Justification for Nonmaterial Nonsubstantive Change to an OMB Approved Information Collection.docx Justification for No Material/Nonsubstantive Change
Att 10_Summary of Changes Table (24BY).docx Supplementary Document
Att_6l_Wake_County_Health_Department_IRB_agreement[1].pdf Supplementary Document
Att_6k_Baylor_Harris_Health_PrEP_Clinic_IRB_agreement[1].pdf Supplementary Document
Att_6j_Bliss_Healthcare_Services_IRB_agreement[1].pdf Supplementary Document
Att_6i_USF_Ybor_Youth_Clinic_IRB_agreement[1].pdf Supplementary Document
Att_6h_Five_Horizons_Health_Services_IRB_agreement[1].pdf Supplementary Document
Att_6g_Amity_Medical_Group_IRB_agreement[1].pdf Supplementary Document
Att_6f_Childrens_Hospital_of_Philadelphia_IRB_agreement[1].pdf Supplementary Document
Att_6e_Childrens_Hospital_Montefiore_IRB_agreement[1].pdf Supplementary Document
Att_6d_Cook_County_HHS_IRB_agreement[1].pdf Supplementary Document
Att_6b_University_of_North_Carolina_Chapel_Hill_IRB_agreement[1].pdf Supplementary Document
Att_6a_Florida_State_University_IRB_Letter_of_Approval[1].pdf Supplementary Document
Att_9_Provider_Training_Summary[1].docx Supplementary Document
Att_7_Data_Use_Plan_EPICC[1].docx Supplementary Document
Att_1_Auth_Legislation[1].docx Supplementary Document
30_Day_FRN_EPICC[1].docx Supplementary Document
SSB_Clean_12.22.25.docx Supporting Statement B
SSA_Clean_12.22.25.docx Supporting Statement A
Aims 1&2 Clinic Assessment (every 6 months) Form and Instruction
Aims 1&2 Clinic Assessment (Baseline & Final) Form and Instruction
Aim 2b Provider Focus Group Guide Form and Instruction
Aim 2b Provider Pre-Focus Group Survey Form and Instruction
Aim 2b Provider Focus Group Contact Information Form and Instruction
Aim 2b Provider Focus Group Screener Form and Instruction
Aim 2a Cohort Exit Interview (English/Spanish) Form and Instruction
Aim 2a Cohort Blood Collection Instructions (English/Spanish) Form and Instruction
Aim 2a Cohort App Setup (English/Spanish) Form and Instruction
Aim 2a Cohort Follow Up Survey (English/Spanish) Form and Instruction
Aim 2a Cohort Baseline Survey (English/Spanish) Form and Instruction
Aim 2a Cohort HIPAA Form (English & Spanish) Form and Instruction
Aim 2a Cohort Contact Information (English/Spanish) Form and Instruction
Aim 2a Cohort Screener (English/Spanish) Form and Instruction
Aim 1 Provider Patient Interaction (Baseline and Final) Form and Instruction
Aim 1 Provider Post-Training Survey Form and Instruction
Aim 1 Provider Pre- Training Survey Form and Instruction
Aim 1 Provider Training Contact Information Form and Instruction
Aim 1 Provider Training Screener Form and Instruction

All Historical Document Collections

202601-0920-013 Approved without change	No material or nonsubstantive change to a currently approved collection	2026-01-30
202509-0920-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2025-09-22
202412-0920-015	No material or nonsubstantive change to a currently approved collection	2024-12-23
202401-0920-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2024-01-08
202309-0920-011 Approved without change	New collection (Request for a new OMB Control Number)	2023-10-31

OMB Details

Aim 1 Provider Training Screener

Federal Enterprise Architecture: Workforce Management - Labor Rights Management

Form 0920-22GA

Att 4a_Aim1ProviderTrainingScreener

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.