Attachment D

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. The panel should assure that HIV educational
sessions and materials do not promote sexual activity or substance abuse (42 U.S.C. 300ee(c).
Following are the names, occupations, organizational affiliations, and target population expertise 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

TARGET POP.
EXPERTISE

Note: For target population expertise, note “General,” if the member has no specific target population expertise.

Applicant/Grantee Name

Program Announcement and Award Number (If Known)

Signature: Project Director

Signature: Authorized Business Official

Date

Date

CDC 0.113 (Revised 9/03-DRAFT)

Statement of Compliance with Content of HIV/AIDS-Related
Written Materials, Pictorials, Audiovisuals, Questionnaires,
Survey Instruments, and Education Sessions

Report of Approval/Disapproval
of HIV/AIDS Prevention Educational Materials
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, Questionnaires, Survey Instruments, and Education Sessions,
published in the Federal Register on June 15, 1992, we certify that the following list of materials were
submitted and reviewed by our Content Review Panel.

Name of Material

Type*

Panel Chair
Signature:

Accountable health
department signature:

Name:

Name:

Title:

Title:

Date:

Date:

* Type: brochure, flyer; poster, video, curriculum, radio/TV, etc.

Date of
Approval

Date of
Disapproval

Statement of Compliance with Content of HIV/AIDS-Related
Written Materials, Pictorials, Audiovisuals, Questionnaires,
Survey Instruments, and Education Sessions

NO REPORT OF APPROVAL/DISAPPROVAL
BY OUR CONTENT REVIEW PANEL NECESSARY
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, Questionnaires, Survey Instruments, and Education Sessions, published in the Federal
Register on June 15, 1992, I certify that from the period of ___________________ through
___________________ that we do not need to send a report of approval/disapproval of materials for the
following reason(s) (check all that apply):

Q

All of the materials we are using have been approved by our content review panel and previously
reported to CDC

Q

We are only using materials previously reviewed and approved by the health department or CDC HIV/AIDS
funded national/regional organizations

Q

We are only using materials developed by CDC or other federal agencies.

Q

We are not using any HIV prevention educational materials in our program

Q

Other (please describe)

Sincerely,
Signature:
Name:
Title: