assurance of compliance form a.doc

ASSURANCE OF COMPLIANCE

with the “REQUIREMENTS FOR CONTENTS OF AIDS-RELATED WRITTEN MATERIALS, PICTORIALS, AUDIOVISUALS, QUESTIONNAIRES, SURVEY INSTRUMENTS, AND EDUCATIONAL SESSIONS IN CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) ASSISTANCE PROGRAMS” By signing and submitting this form, we agree to comply with the specifications set forth in the “Requirements for Contents of AIDS-Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments, and Educational Sessions in Centers for Disease Control and Prevention (CDC) Assistance Programs,” as revised June 15, 1992, 57 Federal Register 26742.

We agree that all written materials, audiovisual materials, pictorials, questionnaires, survey instruments, proposed group educational sessions, educational curricula and like materials will be submitted to a Program Review Panel. The Panel shall be composed of no less than five (5) persons representing a reasonable cross-section of the general population; but which is not drawn predominantly from the intended audience. (See additional requirements in attached contents guidelines, especially paragraph 2.c. (1)(b), regarding composition of Panel.)

We agree that all written materials, audiovisual materials, pictorials, questionnaires, survey instruments, proposed group educational sessions, educational curricula and like materials will be submitted to a Program Review Panel. The Panel shall be composed of no less than five (5) persons representing a reasonable cross-section of the general population; but which is not drawn predominantly from the intended audience. (See additional requirements in attached contents guidelines, especially paragraph 2.c. (1)(b), regarding composition of Panel.)

The Program Review Panel, guided by the CDC Basic Principles (set forth in 57 Federal Register 26742), will review and approve all applicable materials prior to their distribution and use in any activities funded in any part with CDC assistance funds.

Following are the names, occupations, and organizational affiliations of the proposed panel members: (If panel has more members than can be shown here, please indicate additional members on the reverse side.)

(Health Department Representative)

CDC 0.113 (Revised 3/93) Statement of Compliance with Content of HIV/AIDS-Related

Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions

NO NEW HIV/AIDS RELATED MATERIALS FORM

Agency Name:

Date:

Program Announcement:

Award Number:

To comply with the requirements described in the Review of Contents of HIV/AIDS-Related Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions, published in the Federal Register on June 15, 1992, I certify that from the period of ___________________ through ___________________ that all of the materials we are using have been approved by our content review panel. We also certify that we have previously sent documentation of approval or disapproval to CDC for all the materials we are currently using.

Sincerely, Signature:

Name:

Title:

Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions

MATERIALS SUBMITTED WAITING FOR RESPONSE FORM

Agency Name:

Date:

Program Announcement:

Award Number:

To comply with the requirements described in the Review of Contents of HIV/AIDS-Related Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions, published in the Federal Register on June 15, 1992, I certify that from the period of ___________________ through ___________________ our agency submitted materials to our review panel on _______________________ and have not received a response yet. As soon as we receive a response a form signed by the chair of the panel will be forwarded to you in our next quarterly report.

Signature:

Name:

Title:

Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions

SUBMITTED MATERIALS FORM

Agency Name:

Date:

Program Announcement:

Award Number:

To comply with the requirements described in the Review of Contents of HIV/AIDS-Related Written Materials, Pictorials, Audiovisuals, Questioners, Survey Instruments, and Education Sessions, published in the Federal Register on June 15, 1992, I certify that the following list of materials were submitted and reviewed by our Content Review Panel.

Signature:

Name:

Title:

(This page may be duplicated, as necessary.)

CERTIFICATION OF COMPLIANCE

Requirement: Content of AIDS-Related Written Materials, Pictorials, Audiovisuals, Questionnaires, Survey Instruments and Educational Sessions – Recipient Web Site Notices Grant/Cooperative Agreement Number:

Grantee Name: _________________________________________________________

· I certify that this organization has complied with the terms and conditions of the above referenced requirement.

· I certify that the requirement for a web notice is not applicable to this organization. If the requirement is not applicable, please state why Please list below the primary web address(es) (URLs) impacted by this requirement: