Information Collection Request
[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 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-1428 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form 0920-22FZ Clinic Assessment Every Six Months |
Form and Instruction | Unchanged | Repair queued |
| Form 0920-22FZ Clinical Assesment Baseline & Final |
Form and Instruction | Unchanged | Repair queued |
| Form 0920-22FZ Provider Interview |
Form and Instruction | Unchanged | Repair queued |
| Form 0920-22FZ Provider Post-Training Assessment |
Form and Instruction | Unchanged | Repair queued |
| Provider Pre-Training Assessment |
Form and Instruction | Modified | Repair queued |
| Form 0920-22FZ Provider Locator Form |
Form and Instruction | Unchanged | Repair queued |
| Form 0920-22FZ Provider Screening |
Form and Instruction | Unchanged | Missing upstream |
| Form 0920-22FZ Patient Interview Guide |
Form and Instruction | Unchanged | Missing upstream |
| CleverCap App Setup |
Form and Instruction | Modified | Repair queued |
| Patient Quarterly Assessment |
Form and Instruction | Modified | Repair queued |
| Patient Baseline |
Form and Instruction | Modified | Repair queued |
| Form 0920-22FZ Patient Locator Form |
Form and Instruction | Unchanged | Repair queued |
| Patient Screener (English/Spanish) |
Form and Instruction | Modified | Repair queued |
 mChoice_summary of changes memo_011024.docx |
Justification for No Material/Nonsubstantive Change | Uploaded 2024-02-14 | Repair queued |
| Att 9_Provider Training Summary.docx |
Supplementary Document | Uploaded 2024-02-14 | Missing upstream |
 Att 8_Privacy Impact Assessment_mChoice.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 7_Data Use Plan mChoice.docx |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 6d_Callen_Lorde IRB reliance agreement.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 6b_University of Alabama at Birmingham IRB reliance agreement.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 6a_Columbia University IRB approval.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5e_Provider Consent Form.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5d_Provider Consent to Screen.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5c_Patient Interview Consent Form Spanish.pdf |
Supplementary Document | Uploaded 2024-02-14 | Missing upstream |
| Att 5c_Patient Interview Consent Form English.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5b_Patient Consent Form Spanish.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5b_Patient Consent Form English.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5a_Patient Consent to Screen Spanish.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 5a_Patient Consent to Screen_CLEAN.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 3b_Provider Recruitment Materials.docx |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 3a_Patient Recruitment Materials Spanish.docx |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 3a_Patient Recruitment Materials English.docx |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 2a_60-day FRN Pub 6_13_2022.pdf |
Supplementary Document | Uploaded 2024-02-14 | Repair queued |
| Att 1_Auth Legislation.docx |
Supplementary Document | Uploaded 2023-11-15 | Repair queued |
| SSB mChoice.docx |
Supporting Statement B | Uploaded 2023-11-15 | Repair queued |
| SSA_mChoice.docx |
Supporting Statement A | Uploaded 2023-11-15 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 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 |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CDC |
| OMB Control No | 0920-1428 |
| Type of Information Collection | No material or nonsubstantive change to a currently approved collection |
| Previous ICR Reference No | 202309-0920-010 |
| Agency Tracking No | 0920-1428-24DB |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |