attachment-10-assurance of compliance.pdf

ATTACHMENT X: CDC Form 0.1113: Assurance of Compliance with the Requirements for

Contents of AIDS-Related Written Materials

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.)

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.)

NAME OCCUPATION AFFILIATION

(Health Department

Representative)

Applicant/Grantee Name:

Grant Number (If Known):

Signature: Project Director

Signature: Authorized Business Official

Date:

Date:

CDC 0.1113 (E), Rev. 3/1993, CDC Adobe Acrobat 5.0 Electronic Version, 8/2002