Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Dating Matters for Parents: Participant Satisfaction Questionnaire	Form and Instruction	Removed	Available
Parents Matter! for Dating Matters: Participant Satisfaction Questionnaire	Form and Instruction	Removed	Available
Parent Program Manager (PPM) Technical Assistance Tracking form	Form	Removed	Available
Community Capacity/Readiness Assessment	Form and Instruction	Removed	Available
Educator Outcome Survey Follow-up	Form and Instruction	Removed	Available
Master Trainer TA Tracking Form	Form	Removed	Available
Form LLL Student Program Fidelity 8th Grade Session 10	Form and Instruction	Removed	Available
Form JJJ Student Program Fidelity 8th Grade Session 8	Form and Instruction	Removed	Available
Form KKK Student Program Fidelity 8th Grade Session 9	Form and Instruction	Removed	Available
Form III Student Program Fidelity 8th Grade Session 7	Form and Instruction	Removed	Available
Form HHH Student Program Fidelity 8th Grade Session 6	Form and Instruction	Removed	Available
Form GGG Student Program Fidelity 8th Grade Session 5	Form and Instruction	Removed	Available
Form FFF Student Program Fidelity 8th Grade Session 4	Form and Instruction	Removed	Available
Form CCC Student Program Fidelity 8th Grade Session 1 (Standard)	Form and Instruction	Removed	Available
Form EEE Student Program Fidelity 8th Grade Session 3	Form and Instruction	Removed	Available
Form DDD Student Program Fidelity 8th Grade Session 2	Form and Instruction	Removed	Available
Form PPP Parent Curricula Implementer Consent Form for Focus Group Participation	Form and Instruction	Removed	Available
Form OOO Student Curricula Implementer Consent Form For Focus Group Participation	Form and Instruction	Removed	Available
Local Health Department Capacity and Readiness	Form	Removed	Available
Communications Campaign Tracking Form	Form and Instruction	Removed	Available
Form QQ Student Program Fidelity 8th Grade Session 10	Form and Instruction	Removed	Available
Form PP Student Program Fidelity 8th Grade Session 9	Form and Instruction	Removed	Available
Form OO Student Program Fidelity 8th Grade Session 8	Form and Instruction	Removed	Available
Form NN Student Program Fidelity 8th Grade Session 7	Form and Instruction	Removed	Available
Form MM Student Program Fidelity 8th Grade Session 6	Form and Instruction	Removed	Available
Form LL Student Program Fidelity 8th Grade Session 5	Form and Instruction	Removed	Repair queued
Form KK Student Program Fidelity 8th Grade Session 4	Form and Instruction	Removed	Available
Form JJ Student Program Fidelity 8th Grade Session 3	Form and Instruction	Removed	Available
Form II Student Program Fidelity 8th Grade Session 2	Form and Instruction	Removed	Available
Form HH Student Program Fidelity 8th Grade Session 1	Form and Instruction	Removed	Available
Form GG Student Program Fidelity 7th Grade Session 7	Form and Instruction	Removed	Available
Form EE Student Program Fidelity 7th Grade Session 5	Form and Instruction	Removed	Available
Form DD Student Program Fidelity 7th Grade Session 4	Form and Instruction	Removed	Available
Form CC Student Program Fidelity 7th Grade Session 3	Form and Instruction	Removed	Available
Form BB Student Program Fidelity 7th Grade Session 2	Form and Instruction	Removed	Available
Form AA Student Program Fidelity 7th Grade Session 1	Form and Instruction	Removed	Available
Form FF Student Program Fidelity 7th Grade Session 6	Form and Instruction	Removed	Available
Form Z Student Program Fidelity 6th Grade Session 6	Form and Instruction	Removed	Available
Form Y Student Program Fidelity 6th Grade Session 5	Form and Instruction	Removed	Available
Form X Student Program Fidelity 6th Grade Session 4	Form and Instruction	Removed	Available
Form W Student Program Fidelity 6th Grade Session 3	Form and Instruction	Removed	Available
Form U Student Program Fidelity 6th Grade Session 1	Form and Instruction	Removed	Available
Form V Student Program Fidelity 6th Grade Session 2	Form and Instruction	Removed	Available
Form S Parent Program Fidelity 7th Grade Session 3	Form	Removed	Available
Form R Parent Program Fidelity 7th Grade Session 1	Form	Removed	Available
Form T Parent Program Fidelity 7th Grade Session 5	Form	Removed	Available
Form L Parent Program Fidelity 6th Grade Session 2	Form	Removed	Available
Form Q Parent Program Fidelity 6th Grade Session 6	Form	Removed	Available
Form O Parent Program Fidelity 6th Grade Session 5	Form	Removed	Available
Form N Parent Program Fidelity 6th Grade Session 3	Form	Removed	Available
Form M Parent Program Fidelity 6th Grade Session 2	Form	Removed	Available
School Leadership Capacity and Readiness Survey	Form and Instruction	Removed	Available
Brand Ambassador Implementation Survey	Form and Instruction	Removed	Available
Educator Outcome Survey (Baseline)	Form and Instruction	Removed	Available
Parent/Guardian Consent Form	Form and Instruction	Removed	Available
Parent Outcome Survey Follow-up	Form and Instruction	Removed	Available
Parent/Guardian Survey	Form and Instruction	Removed	Available
Form 4 Attachment G: School Indicators	Form and Instruction	Removed	Available
Student Outcome Survey Follow-Up with High School Items	Form	Modified	Available
Student Outcome Survey Baseline	Form and Instruction	Removed	Available
Parent Guardian Consent Form-High School Chicago.docx	Supplementary Document	Uploaded 2016-06-07	Available
Attachment E- Screenshots.docx	Supplementary Document	Uploaded 2016-01-11	Available
Attachment C IRB Approval.docx	Supplementary Document	Uploaded 2016-01-11	Available
Attachment B2 Public Comment.pdf	Supplementary Document	Uploaded 2016-01-11	Available
Attachment B1 Public Comment.pdf	Supplementary Document	Uploaded 2016-01-11	Repair queued
Attachment B 60Dy FRN 0941 Eval Datting Matters.pdf	Supplementary Document	Uploaded 2016-01-11	Available
Attachment A_Authorizing_Legislation.docx	Supplementary Document	Uploaded 2016-01-11	Available
SSB_0941 DatingMatters111515.docx	Supporting Statement B	Uploaded 2016-01-11	Available
SSA_0941 DatingMatters_07JUN2016.docx	Supporting Statement A	Uploaded 2016-06-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206026	7th Grade Curricula Parent Satisfaction Questionnaire	Instruction	Removed
206026	7th Grade Curricula Parent Satisfaction Questionnaire	Form and Instruction	Removed	Dating Matters for Parents: Participant Satisfaction Questionnaire
206025	6th Grade Curricula Parent Satisfaction Questionnaire	Form and Instruction	Removed	Parents Matter! for Dating Matters: Participant Satisfaction Questionnaire
206024	Parent Program Manager TA Tracking Form	Form	Removed	Parent Program Manager (PPM) Technical Assistance Tracking form
206023	Communications Focus Groups	Instruction	Removed
206022	Community Capacity/Readiness Assessment	Form and Instruction	Removed	Community Capacity/Readiness Assessment
206021	Educator Outcome Evaluation Survey-Follow-up	Form and Instruction	Removed	Educator Outcome Survey Follow-up
201415	STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	Form	Removed	Master Trainer TA Tracking Form
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 10
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 8
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 9
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 7
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 6
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 5
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 4
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 1 (Standard)
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 3
201414	Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 2
201413	Parent Curricula Implementer Focus Group Guide	Other-Focus Group Guide	Removed
201413	Parent Curricula Implementer Focus Group Guide	Form and Instruction	Removed	Parent Curricula Implementer Consent Form for Focus Group Participation
201412	Student Curricula Implementer Focus Group Guide	Form and Instruction	Removed	Student Curricula Implementer Consent Form For Focus Group Participation
201412	Student Curricula Implementer Focus Group Guide	Other-Focus Group Guide	Removed
201411	Student Participant Focus Group	Instruction	Removed
201410	Local Health Department Capacity and Readiness	Form	Removed	Local Health Department Capacity and Readiness
201409	Communications Campaign Tracking	Form and Instruction	Removed	Communications Campaign Tracking Form
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 10
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 9
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 8
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 7
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 6
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 5
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 4
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 3
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 2
201408	Student Program Fidelity 8th Grade Sessions 1 - 10	Form and Instruction	Removed	Student Program Fidelity 8th Grade Session 1
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 7
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 5
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 4
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 3
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 2
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 1
201407	Student Program Fidelity 7th Grade Sessions 1 - 7	Form and Instruction	Removed	Student Program Fidelity 7th Grade Session 6
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 6
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 5
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 4
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 3
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 1
201406	Student Program Fidelity 6th Grade Sessions 1 - 6	Form and Instruction	Removed	Student Program Fidelity 6th Grade Session 2
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Removed	Parent Program Fidelity 7th Grade Session 3
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Removed	Parent Program Fidelity 7th Grade Session 1
201405	Parent Program Fidelity 7th Grade Sessions 1, 3, 5	Form	Removed	Parent Program Fidelity 7th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Removed	Parent Program Fidelity 6th Grade Session 2
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Removed	Parent Program Fidelity 6th Grade Session 6
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Removed	Parent Program Fidelity 6th Grade Session 5
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Removed	Parent Program Fidelity 6th Grade Session 3
201404	Parent Program Fidelity 6th Grade Sessions 1-6	Form	Removed	Parent Program Fidelity 6th Grade Session 2
201403	School Leadership Capacity and Readiness Survey	Form and Instruction	Removed	School Leadership Capacity and Readiness Survey
201402	Brand Ambassador Implementation Survey	Form and Instruction	Removed	Brand Ambassador Implementation Survey
201401	Educator Outcome Survey Baseline	Form and Instruction	Removed	Educator Outcome Survey (Baseline)
201400	Parent Outcome Follow-up Survey	Form and Instruction	Removed	Parent/Guardian Consent Form
201400	Parent Outcome Follow-up Survey	Form and Instruction	Removed	Parent Outcome Survey Follow-up
201399	Parent Outcome Baseline Survey	Form and Instruction	Removed	Parent/Guardian Survey
201398	School Indicators	Form and Instruction	Removed	Attachment G: School Indicators
201397	Student Outcome Survey Follow-up - High School	Form	Modified	Student Outcome Survey Follow-Up with High School Items
201395	Student Outcome Survey Baseline	Form and Instruction	Removed	Student Outcome Survey Baseline

ICR Details

OMB Control No: 0920-0941	ICR Reference No: 201512-0920-010
Status: Historical Active	Previous ICR Reference No: 201408-0920-001
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0941
Title: Evaluation of Dating Matters: Strategies to Promote Healthy Teen Relationships
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/07/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/14/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2019	36 Months From Approved	06/30/2016
Responses	4,399	0	52,897
Time Burden (Hours)	3,299	0	28,814
Cost Burden (Dollars)	0	0	0

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Abstract: Dating Matters is a comprehensive approach to prevent teen dating violence among youth in high-risk urban communities. Dating Matters consists of evidence-based or evidence-informed prevention strategies implemented at each level of the social ecology. Continue longitudinal follow-up for CDC's teen dating violence (TDV) prevention initiative, Dating Matters®: Strategies to Promote Healthy Teen Relationships. This Revision seeks to extend this existing approval through May 31, 2019 to continue collecting high school follow-up data only on the remaining cohorts of middle school intervention participants.

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Authorizing Statute(s): US Code: 42 USC 301 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57185	09/22/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 1190	01/11/2016
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
6th Grade Curricula Parent Satisfaction Questionnaire	none	Parents Matter! for Dating Matters: Participant Satisfaction Questionnaire
7th Grade Curricula Parent Satisfaction Questionnaire	none	Dating Matters for Parents: Participant Satisfaction Questionnaire
Brand Ambassador Implementation Survey	None	Brand Ambassador Implementation Survey
Communications Campaign Tracking	None	Communications Campaign Tracking Form
Communications Focus Groups
Community Capacity/Readiness Assessment	none	Community Capacity/Readiness Assessment
Educator Outcome Evaluation Survey-Follow-up	none	Educator Outcome Survey Follow-up
Educator Outcome Survey Baseline	None	Educator Outcome Survey (Baseline)
Local Health Department Capacity and Readiness	None	Local Health Department Capacity and Readiness
Parent Curricula Implementer Focus Group Guide	PPP	Parent Curricula Implementer Consent Form for Focus Group Participation
Parent Outcome Baseline Survey	none	Parent/Guardian Survey
Parent Outcome Follow-up Survey	None, none	Parent Outcome Survey Follow-up ,   Parent/Guardian Consent Form
Parent Program Fidelity 6th Grade Sessions 1-6	M, N, O, Q, L	Parent Program Fidelity 6th Grade Session 2 ,   Parent Program Fidelity 6th Grade Session 3 ,   Parent Program Fidelity 6th Grade Session 5 ,   Parent Program Fidelity 6th Grade Session 6 ,   Parent Program Fidelity 6th Grade Session 2
Parent Program Fidelity 7th Grade Sessions 1, 3, 5	T, R, S	Parent Program Fidelity 7th Grade Session 5 ,   Parent Program Fidelity 7th Grade Session 1 ,   Parent Program Fidelity 7th Grade Session 3
Parent Program Manager TA Tracking Form	none	Parent Program Manager (PPM) Technical Assistance Tracking form
STUDENT PROGRAM MASTER TRAINER TECHNICAL ASSISTANCE TRACKING FORM	None	Master Trainer TA Tracking Form
School Indicators	4	Attachment G: School Indicators
School Leadership Capacity and Readiness Survey	None	School Leadership Capacity and Readiness Survey
Student Curricula Implementer Focus Group Guide	OOO	Student Curricula Implementer Consent Form For Focus Group Participation
Student Outcome Survey Baseline	None	Student Outcome Survey Baseline
Student Outcome Survey Follow-up - High School	NA	Student Outcome Survey Follow-Up with High School Items
Student Participant Focus Group
Student Program Fidelity 6th Grade Sessions 1 - 6	V, U, W, X, Y, Z	Student Program Fidelity 6th Grade Session 2 ,   Student Program Fidelity 6th Grade Session 1 ,   Student Program Fidelity 6th Grade Session 3 ,   Student Program Fidelity 6th Grade Session 4 ,   Student Program Fidelity 6th Grade Session 5 ,   Student Program Fidelity 6th Grade Session 6
Student Program Fidelity 7th Grade Sessions 1 - 7	AA, BB, CC, DD, EE, FF, GG	Student Program Fidelity 7th Grade Session 1 ,   Student Program Fidelity 7th Grade Session 2 ,   Student Program Fidelity 7th Grade Session 3 ,   Student Program Fidelity 7th Grade Session 4 ,   Student Program Fidelity 7th Grade Session 5 ,   Student Program Fidelity 7th Grade Session 6 ,   Student Program Fidelity 7th Grade Session 7
Student Program Fidelity 8th Grade Sessions 1 - 10	HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ	Student Program Fidelity 8th Grade Session 1 ,   Student Program Fidelity 8th Grade Session 2 ,   Student Program Fidelity 8th Grade Session 3 ,   Student Program Fidelity 8th Grade Session 4 ,   Student Program Fidelity 8th Grade Session 5 ,   Student Program Fidelity 8th Grade Session 6 ,   Student Program Fidelity 8th Grade Session 7 ,   Student Program Fidelity 8th Grade Session 8 ,   Student Program Fidelity 8th Grade Session 9 ,   Student Program Fidelity 8th Grade Session 10
Student Program Fidelity 8th Grade Sessions 1 - 10 (Standard)	DDD, EEE, CCC, FFF, GGG, HHH, III, KKK, JJJ, LLL	Student Program Fidelity 8th Grade Session 2 ,   Student Program Fidelity 8th Grade Session 3 ,   Student Program Fidelity 8th Grade Session 1 (Standard) ,   Student Program Fidelity 8th Grade Session 4 ,   Student Program Fidelity 8th Grade Session 5 ,   Student Program Fidelity 8th Grade Session 6 ,   Student Program Fidelity 8th Grade Session 7 ,   Student Program Fidelity 8th Grade Session 9 ,   Student Program Fidelity 8th Grade Session 8 ,   Student Program Fidelity 8th Grade Session 10

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,399	52,897	0	-48,498	0	0
Annual Time Burden (Hours)	3,299	28,814	0	-25,515	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Reduction in Burden Hours is a result of continued collection of follow-up data from only the remaining cohorts of high school students.

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Annual Cost to Federal Government: $914,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/14/2016

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