Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 3 Attachment A: Draft Workforce Safety Supplemental Item	Form and Instruction	New	Available
Form 2 Attachment C: Hospital Point of Contact (POC) Instructions	Form and Instruction	New	Available
Form 1 Draft Workforce Safety Cognitive Interview Guide	Form and Instruction	New	Available
Form 3 Attachment C - Patient Interview Guide	Form and Instruction	New	Available
Form 2 Attachment B - Health Information Technology Professional Interview Guide	Form and Instruction	New	Available
Form 1 Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)	Form and Instruction	New	Available
Form 5 Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx	Form and Instruction	New	Available
Form 4 Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx	Form and Instruction	New	Available
Form 3 Pilot test	Form and Instruction	New	Available
Form 2 Medical office information survey	Form and Instruction	New	Available
Form 1 Attachment B: Draft Diagnostic Safety Cognitive Interview Guide	Form and Instruction	New	Available
Form 2 Attachment E SPPC II Short Questionnaire Final	Form and Instruction	New	Available
Form 1 Attachment B- Field Test Interview Guides Final	Form and Instruction	New	Available
Form 2 Attachment E – SPPC-II Field Test - Short Questionnaire	Form and Instruction	New	Available
Form 1 Attachment B – Field Test Interview Guides	Form and Instruction	New	Available
Form 2 Attachment D Intensive interview protocol 2019-03-11.docx	Form and Instruction	New	Available
Form 1 Attachment B Child HCAHPS Survey 2019-03-11.docx	Form and Instruction	New	Available
Form 2 CG-CAHPS EZ /CG-CAHPS - Spanish	Form and Instruction	New	Available
Form 1 CG-CAHPS EZ /CG-CAHPS - English	Form and Instruction	New	Available
Form 2 In Depth Screening	Form and Instruction	New	Available
Form 1 Initial Screening	Form and Instruction	New	Available
Form 3 Attachment G – Interview Protocol	Form and Instruction	New	Available
Form 2 In Depth Screening	Form and Instruction	New	Available
Form 1 Initial Screening	Form and Instruction	New	Available
Form 3 Attachment G – Interview Guide	Form and Instruction	New	Available
Form 2 In Depth Screening	Form and Instruction	New	Available
Form 1 Screening	Form and Instruction	New	Available
Form 3 Attachment G – Focus Group Protocol	Form and Instruction	New	Available
Form 2 In Depth Screening	Form and Instruction	New	Available
Form 1 Initial Screening	Form and Instruction	New	Available
Form 3 Attachment G – Interview Protocol	Form and Instruction	New	Available
Form 3 Attachment D: Process Usage Worksheet (Providers)	Form and Instruction	New	Available
Form 2 Process Usage Worksheet (Patients)	Form and Instruction	New	Available
Form 1 Attachment A. PROMIS Item Bank V2.0	Form and Instruction	New	Available
Form 4 Attachment G – Focus Group Protocol	Form and Instruction	New	Available
Form 3 Attachment D – Participant Consent Form	Form and Instruction	New	Available
Form 2 Attachment B – In-depth Screening Questionnaire	Form and Instruction	New	Available
Form 1 Attachment A – Initial Screening Questionnaire	Form and Instruction	New	Available
Form C1 Attachment C1 - Cognitive Interview Guide and Questionnaire	Form and Instruction	Removed	Available
Form B1 Attachment B – Screening Questionnaire	Form and Instruction	Removed	Available
Form 3 Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide	Form and Instruction	Removed	Available
Form 2 Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide	Form and Instruction	Removed	Available
Form 1 Attachment A – HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide	Form and Instruction	Removed	Available
Form 7 Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone	Form and Instruction	Removed	Available
Form 5 Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone	Form and Instruction	Removed	Available
Form 3 Attachment C: Interview Guide for Case Study Development- Telephone	Form and Instruction	Removed	Available
Form 1 Attachment A: Key Informant Interview Guide- Telephone	Form and Instruction	Removed	Available
Form 8 Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person	Form and Instruction	Removed	Available
Form 6 Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person	Form and Instruction	Removed	Available
Form 4 Attachment D: Interview Guide for Case Study Development- In-person	Form and Instruction	Removed	Available
Form 2 Attachment B: Key Informant Interview Guide- In-person	Form and Instruction	Removed	Available
Supporting Statement Part B -- Generic Pretesting Clearance 2014.doc	Supporting Statement B	Uploaded 2014-09-05	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-03-31	Available
Attachment B -- Examples.doc	Supplementary Document	Uploaded 2011-03-31	Available
Supporting Statement Part A -Pesting Clearance 2017.doc	Supporting Statement A	Uploaded 2017-08-01	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243252	Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture	Form and Instruction	New	Attachment A: Draft Workforce Safety Supplemental Item
243252	Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture	Form and Instruction	New	Attachment C: Hospital Point of Contact (POC) Instructions
243252	Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture	Form and Instruction	New	Draft Workforce Safety Cognitive Interview Guide
241846	Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	Form and Instruction	New	Attachment C - Patient Interview Guide
241846	Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	Form and Instruction	New	Attachment B - Health Information Technology Professional Interview Guide
241846	Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	Form and Instruction	New	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers)
235839	Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction	New	Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx
235839	Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction	New	Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx
235839	Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction	New	Pilot test
235839	Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction	New	Medical office information survey
235839	Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	Form and Instruction	New	Attachment B: Draft Diagnostic Safety Cognitive Interview Guide
235532	Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	Form and Instruction	New	Attachment E SPPC II Short Questionnaire Final
235532	Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	Form and Instruction	New	Attachment B- Field Test Interview Guides Final
235532	Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	Form and Instruction	New	Attachment E – SPPC-II Field Test - Short Questionnaire
235532	Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	Form and Instruction	New	Attachment B – Field Test Interview Guides
235487	Pilot Test of the Protocol for Eliciting Patient Narratives from Parents for the Child Hospital Consumer Assessment of Healthcare	Form and Instruction	New	Attachment D Intensive interview protocol 2019-03-11.docx
235487	Pilot Test of the Protocol for Eliciting Patient Narratives from Parents for the Child Hospital Consumer Assessment of Healthcare	Form and Instruction	New	Attachment B Child HCAHPS Survey 2019-03-11.docx
235470	Field Test of Low Literacy Version of CAHPS Clinician and Group Survey	Form and Instruction	New	CG-CAHPS EZ /CG-CAHPS - Spanish
235470	Field Test of Low Literacy Version of CAHPS Clinician and Group Survey	Form and Instruction	New	CG-CAHPS EZ /CG-CAHPS - English
234711	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges	Form and Instruction	New	In Depth Screening
234711	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges	Form and Instruction	New	Initial Screening
234711	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges	Form and Instruction	New	Attachment G – Interview Protocol
234710	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually	Form and Instruction	New	In Depth Screening
234710	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually	Form and Instruction	New	Initial Screening
234710	Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually	Form and Instruction	New	Attachment G – Interview Guide
234708	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	Form and Instruction	New	In Depth Screening
234708	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	Form and Instruction	New	Screening
234708	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	Form and Instruction	New	Attachment G – Focus Group Protocol
234706	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments	Form and Instruction	New	In Depth Screening
234706	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments	Form and Instruction	New	Initial Screening
234706	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments	Form and Instruction	New	Attachment G – Interview Protocol
234239	Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology	Form and Instruction	New	Attachment D: Process Usage Worksheet (Providers)
234239	Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology	Form and Instruction	New	Process Usage Worksheet (Patients)
234239	Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology	Form and Instruction	New	Attachment A. PROMIS Item Bank V2.0
234065	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	Form and Instruction	New	Attachment G – Focus Group Protocol
234065	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	Form and Instruction	New	Attachment D – Participant Consent Form
234065	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	Form and Instruction	New	Attachment B – In-depth Screening Questionnaire
234065	Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	Form and Instruction	New	Attachment A – Initial Screening Questionnaire
226530	Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module	Form and Instruction	Removed	Attachment C1 - Cognitive Interview Guide and Questionnaire
226530	Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module	Form and Instruction	Removed	Attachment B – Screening Questionnaire
226380	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	Form and Instruction	Removed	Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide
226351	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	Form and Instruction	Removed	Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide
226350	Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	Form and Instruction	Removed	Attachment A – HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment C: Interview Guide for Case Study Development- Telephone
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment A: Key Informant Interview Guide- Telephone
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment D: Interview Guide for Case Study Development- In-person
219183	Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	Form and Instruction	Removed	Attachment B: Key Informant Interview Guide- In-person

ICR Details

OMB Control No: 0935-0124	ICR Reference No: 201708-0935-002
Status: Historical Active	Previous ICR Reference No: 201409-0935-002
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/03/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/07/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2020	36 Months From Approved	11/30/2017
Responses	13,800	0	4,600
Time Burden (Hours)	8,900	0	2,967
Cost Burden (Dollars)	0	0	0

---

Abstract: Work conducted under this clearance is intended to improve AHRQ's current data collections by developing new surveys and revising surveys and to test survey instruments more quickly.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 19727	04/28/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 35205	07/28/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Advancing the Collection and Use of Patient –Reported Outcomes through Health Information Technology	2, 1, 3	Attachment A. PROMIS Item Bank V2.0 ,   Process Usage Worksheet (Patients) ,   Attachment D: Process Usage Worksheet (Providers)
Cognitive Testing of the Medical Expenditure Panel Survey (MEPS) Health Insurance Verification Module	C1, B1	Attachment B – Screening Questionnaire ,   Attachment C1 - Cognitive Interview Guide and Questionnaire
Environmental Scan for Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families	6, 4, 2, 8, 7, 1, 3, 5	Attachment B: Key Informant Interview Guide- In-person ,   Attachment D: Interview Guide for Case Study Development- In-person ,   Attachment F: Interview Guide for Patients/Family Members/Caregivers- In-person ,   Attachment H: Interview Guide for Primary Care Practice Staff and Physicians- In-person ,   Attachment A: Key Informant Interview Guide- Telephone ,   Attachment C: Interview Guide for Case Study Development- Telephone ,   Attachment E: Interview Guide for Patients/Family Members/Caregivers- Telephone ,   Attachment G: Interview Guide for Primary Care Practice Staff and Physicians- Telephone
Field Test of Low Literacy Version of CAHPS Clinician and Group Survey	1, 2	CG-CAHPS EZ /CG-CAHPS - English ,   CG-CAHPS EZ /CG-CAHPS - Spanish
Field Test of SPPC-II Toolkit and Training Modules during Pilot Phase of SPPC-II Demonstration Project	2, 1, 2, 1	Attachment B – Field Test Interview Guides ,   Attachment E – SPPC-II Field Test - Short Questionnaire ,   Attachment B- Field Test Interview Guides Final ,   Attachment E SPPC II Short Questionnaire Final
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	2	Attachment B – HAC Risk Dashboard Tool Low-Fidelity Prototype Evaluation Focus Group Guide
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	1	Attachment A – HAC Risk Dashboard Tool Information Needs Identification Focus Group Guide
Identifying, Assessing, and Balancing Competing Risks of Multiple Hospital-Acquired Conditions (HACs)	3	Attachment C – HAC Risk Dashboard Tool Key Informant Interview Guide
Implementation of an Electronic Care Plan for People with Multiple Chronic Conditions	1, 2, 3	Attachment A - Healthcare Staff Interview Guide (for providers & non-providers) ,   Attachment B - Health Information Technology Professional Interview Guide ,   Attachment C - Patient Interview Guide
Pilot Test of the Proposed Diagnostic Safety Supplemental Item Set for the Medical Office Survey on Patient Safety Culture	3, 2, 1, 4, 5	Attachment B: Draft Diagnostic Safety Cognitive Interview Guide ,   Medical office information survey ,   Pilot test ,   Attachment A - Draft Diagnostic Safety Supplemental Item Set 7-3-19.docx ,   Attachment B - Diagnostic Safety Cog Interview Guide 7-3-19.docx
Pilot Test of the Proposed Workforce Safety Supplemental Item Set For the Surveys on Patient Safety Culture	2, 3, 1	Draft Workforce Safety Cognitive Interview Guide ,   Attachment C: Hospital Point of Contact (POC) Instructions ,   Attachment A: Draft Workforce Safety Supplemental Item
Pilot Test of the Protocol for Eliciting Patient Narratives from Parents for the Child Hospital Consumer Assessment of Healthcare	2, 1	Attachment B Child HCAHPS Survey 2019-03-11.docx ,   Attachment D Intensive interview protocol 2019-03-11.docx
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality - Insurance Plans Purchased Individually	1, 2, 3	Attachment G – Interview Guide ,   Initial Screening ,   In Depth Screening
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality – Marketplaces and Exchanges	1, 2, 3	Attachment G – Interview Protocol ,   Initial Screening ,   In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Employer-sponsored Insurance Plans	3, 4, 1, 2	Attachment A – Initial Screening Questionnaire ,   Attachment B – In-depth Screening Questionnaire ,   Attachment D – Participant Consent Form ,   Attachment G – Focus Group Protocol
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by Local Governments	3, 1, 2	Attachment G – Focus Group Protocol ,   Screening ,   In Depth Screening
Testing for Potential Enhancements to the Medical Expenditure Panel Survey: Study on Insurance Plans offered by State Governments	3, 1, 2	Attachment G – Interview Protocol ,   Initial Screening ,   In Depth Screening

---

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	13,800	4,600	0	9,200	0	0
Annual Time Burden (Hours)	8,900	2,967	0	5,933	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: These are the same number requested for this Generic Clearance three years ago.

---

Annual Cost to Federal Government: $705,392

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

---

Common Form ICR:  No

---

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: 08/07/2017

---