FOA - Instructions for Preparing an APR

Centers for Disease Control and Prevention (CDC)

Procurement and Grants Office

Instructions for Preparing an Annual Performance Report (APR)

Catalog of Federal Domestic Assistance (CFDA): 93.944

Funding Opportunity Announcement (FOA) Number: CDC-RFA-PS13-130205CONT17

National HIV Surveillance System (NHSS)
0920-0573 Expires 6/30/2019

Eligibility:

This award will be a continuation of funds intended only for grantees previously awarded under CDC-RFA-PS13-1302: National HIV Surveillance System (NHSS).

Application Submission:

CDC requires grantees to submit their Annual Performance Reports (APR), which serves as the continuation application, through www.Grants.gov NLT 120 days prior to the end of the budget period.

If you encounter any difficulties submitting your annual performance report through www.Grants.gov, please contact CDC’s Technical Information Management Section at 770-488-2700 prior to the submission deadline. If you need further information regarding the annual performance report process, please contact Constance Jarvis, Grants Management Specialist at (770) 488-5859. For programmatic information, please contact Lydia Blasini-Alcivar, at [email protected] or 404-639-4108.

Reports must be submitted by August 15, 2016, 11:59 p.m. Eastern Standard Time on www.Grants.gov for Reporting Period 7/1/2015- 6/30/2016. Late or incomplete reports could result in an enforcement action such as a delay in the award or a reduction in funds. CDC will accept requests for a deadline extension on rare occasions and after adequate justification has been provided.

Performance Reporting Special Notice: The Annual Performance Report is due no later than 120 days prior to the end of the budget period, December 31, 2015, and also serves as the continuing application. This report should include the information specified in the FOA. The current budget period is January 2016 to December 2016. The APR due date is August 15, 2016 and the APR reporting period is July 1, 2015 to June 30, 2016.

General Application Packet Tips:

• Properly label each item of the application packet.

• Each section should use 1.5 spacing with one-inch margins.

• Number all narrative pages only.

• This report must not exceed 44 pages, excluding attachments separately submitted.

Case Surveillance – Component A 25 pages

• Molecular HIV Surveillance (MHS)* 03 pages

• Perinatal HIV Exposure Reporting Surveillance (PHERS)* 03 pages

• Geocoding and Data Linkage* 03 pages

(*If conducted as part of Case Surveillance activities, optional activities total pages are inclusive of the 25 pages for Case Surveillance.)

HIV Incidence Surveillance – Component B 10 pages

• CDC requires the use of PDF format for ALL attachments.

• Use of file formats other than PDF may result in the file being unreadable by CDC staff.

• Directions for creating PDF files can be found on www.Grants.gov

Checklist of required contents of application packet:

1. PS13-1302

• SF-424 Application for Federal Domestic Assistance-Short Organizational Form

• SF-424A Budget Information-Non-Construction Programs

• Certification of Compliance with the NCHHSTP Data Security and Confidentiality Standards and Designation of Overall Responsible Party (ORP)

• Budget Justification

• Indirect Cost Rate Agreement

• Project Narrative for PS13-1302 only (for progress towards objectives for the period July 1, 2015 to June 30, 2016)

• Program Implementation Plan and Timeline for budget year 2017

Instructions for accessing and completing required contents of the application package:

1. Go to: www.Grants.gov

2. Select: “Apply for Grants”

3. Select: “Step 1: Download a Grant Application”

4. Insert the CDC-RFA-PS13-130205CONT17

5. Download application package and complete all sections

1. SF-424 Application for Federal Domestic Assistance-Short Organizational Form:

Complete all sections:

1. In addition to inserting the legal name of your organization in Block #5a, insert the CDC Award Number provided in the CDC Notice of Award. Failure to provide your award number could cause delay in processing your application.

2. Please insert your organization’s Business Official information in Block #8.

SPECIAL NOTE: Items 2, 3, and 4 should be attached to the application through the “Mandatory Documents” section of the “Grant Application” page. Select “Other Attachments Form” and attach as a PDF file.

2. SF-424A Budget Information and Justification:

1. Download the form from www.grants.gov.

2. Complete all applicable sections.

3. Estimated Un-obligated

   1. Awardees may request up to 75% of anticipated unobligated funds at the end of the current budget period.

   2. If use of estimated un-obligated funds is requested in addition to funding for the next year, complete all columns in Section A of SF-424A and submit an interim

Federal Financial Report (FFR), Standard Form-425, available on the CDC internet at:  http://grants.nih.gov/grants/forms.htm

4. The estimated un-obligated balance should be realistic in order to be consistent with the annual FFR to be submitted hardcopy (previously via eRA Commons) to your Grants Management Specialist and to your Grants Management Officer following the end of the budget period.

5. Based on the current rate of obligation, if it appears there will be un-obligated funds at the end of the current budget period, provide detailed actions that will be taken to obligate this amount.

6. If it appears there will be insufficient funds

1. Provide detailed justification of the shortfall

2. List the actions taken to bring the obligations in line with the authorized funding level.

7. The proposed budget should be based on the federal funding level stated in the letter from CDC.

8. In a separate narrative, provide a detailed, line-item budget justification of the funding amount requested to support the activities to be carried out with those funds. Attach in the “Mandatory Documents” box under “Budget Narrative Attachment Form.” Document needs to be in the PDF format.

9. The budget justification must be prepared in the general form, format, and to the level of detail as described in the CDC Budget Guidance. The sample budget guidance is provided on CDC’s internet at: http://www.cdc.gov/grants/interestedinapplying/applicationresources.html. For any new proposed subcontracts, provide the information specified in the Budget Guidance.

10. When non-federal matching is required, provide a line-item list of non-federal contributions including source, amount, and/or value of third party contributions proposed to meet a matching requirement.

3. Indirect Cost Rate Agreement (This is not applicable to grantees subject to OMB Guidance A-21 – Educational Institutions. The rates stay the same as the first year award.):

1. If indirect costs are requested, include a copy of the current negotiated federal indirect cost rate agreement or a cost allocation plan approval letter for those Grantees under such a plan.

2. Clearly describe the method used to calculate indirect costs. Make sure the method is consistent with the Indirect Cost Rate Agreement.

3. To be entitled to use indirect cost rates, a rate agreement must be in effect at the start of the budget period.

4. If an Indirect Cost Rate Agreement is not in effect, indirect costs may be charged as direct if (1) this practice is consist with the grantee’s/applicant’s approved accounting practices; and (2) if the costs are adequately supported and justified. Please see the Budget Guidelines (http://www.cdc.gov/grants/interestedinapplying/applicationresources.html) for additional information.

5. If applicable, attach in the “Mandatory Documents” box under “Other Attachments Form”. Name document “Indirect Cost Rate.”

4. Estimated Funding:

1. Total FY17 HICSB funds for CDC-RFA-PS13-130205CONT16 will be $61,390,839

1. Case Surveillance: $49,051,322

2. Direct Assistance: $1,188,595

3. Incidence: $6,590,472

4. Optional (if funds are available)

• MHS: $1,353,948

• Perinatal HIV Exposure: $2,071,125

• Geocoding and Census Data Linkage: $1,234,995

5. Project Narrative

1. PS13-1302 - Current Budget Period Progress (July 1, 2015 to June 30, 2016):

Please provide a narrative report of progress for Case Surveillance, Incidence Surveillance, and Optional Activities from July 1, 2015 to June 30, 2016. This report should:

1. Cover activities that took place during the period of July 1, 2015 through June 30, 2016, as stated in the terms and conditions of your Year 4 award.

2. Be attached in the “Mandatory Documents” box under “Project Narrative Attachment Form.” The document needs to be in PDF format.

3. Provide a corrective action plan for each objective you are “not expecting to meet” that describes concise specific actions to assess the cause of the problem, correct the problem, and follow the outcomes of the prescribed actions over time to assure that the desired outcomes are sustained over time. Also, include a discussion of technical assistance needed to assist in resolving the situation.

4. For each Component use this format:

• Recipient activity.

• Program objective(s).

• Discussion of progress towards accomplishing the objective.

• Corrective action plans if “not expecting to meet.”

Progress narrative for Case Surveillance (25 page limit) – For each of the “Recipient Activities” below, please provide a narrative description of progress towards achieving program’s objectives and activities as provided in the FOA 13-1302 application. Please be specific in describing the accomplishment of activities which will lead to the attainment of the related objective. Please use quantitative terms whenever possible to assist us in understanding the quality of your performance.

You must address the following:

1. Identify and report persons with HIV infection.

2. Conduct death ascertainment.

3. Conduct intrastate de-duplication of HIV cases.

4. Participate in routine interstate de-duplication review (RIDR) of HIV cases.

5. Conduct risk factor ascertainment.

6. Collect HIV laboratory reports.

7. Assess data quality.

8. Investigate cases of public health importance (COPHI).

9. Conduct evaluation of the HIV surveillance system.

10. Conduct analysis of HIV surveillance data and disseminate findings.

11. Report data to CDC.

12. Integrate case and incidence surveillance.

13. Integrate program activities to enhance efficiency and improve outcomes.

14. Attend CDC sponsored meetings.

15. Implement and adhere to data security and confidentiality guidelines.

16. Implement National HIV Surveillance System software requirements.

17. Other Case Surveillance Activities (MHS, PHERS, Geocoding): If the jurisdiction conducted any of these activities as part of case surveillance, please provide a narrative description of the activities conducted (as listed below) and progress.

MHS Activities (3 pages):

You must address the following:

1. Secure and confidential reporting of HIV surveillance data.

2. Review state or local HIV laws and regulations regarding the reporting of HIV nucleotide sequence data.

3. Collaborate with laboratories performing HIV genotypic drug resistance testing.

4. Obtain all HIV nucleotide sequence data for persons diagnosed with HIV infection.

5. Validate HIV nucleotide sequence data.

6. Import all nucleotide sequence data into eHARS.

7. Collect antiretroviral use history data for all persons newly diagnosed with HIV infection.

8. Report all data to CDC.

9. Conduct ongoing monitoring of data quality and evaluation of local activities.

10. Analyze data, including transmitted drug resistance.

11. Develop and disseminate data reports and presentations.

PHERS Activities (3 pages):

You must address the following:

1. Conduct active and passive surveillance for perinatal HIV exposure.

2. Conduct longitudinal follow-up of all HIV exposed children.

3. Conduct medical record review to assess for opportunistic infections.

4. Assess potential adverse outcomes of AVR exposure.

5. Conduct linkage of HIV and birth registries.

6. Conduct active and passive surveillance for HIV-infected pregnant women.

7. Conduct activities to improve the quality, efficiency, and productivity of perinatal exposure surveillance.

8. Conduct an evaluation of the perinatal HIV surveillance program as defined in the Technical Guidance for HIV Surveillance Programs Volume I: Policies and Procedures document.

9. Report data to CDC.

10. Analyze and disseminate perinatal HIV surveillance data and promote their use for prevention and health services planning and evaluation.

11. Implement and adhere to Data Security and Confidentiality Guidelines.

12. Attend CDC sponsored meetings.

Geocoding Activities (3 pages):

You must address the following:

1. Collect HIV surveillance information according to routine surveillance procedures (Required data elements include local street address, city, and state of residence at diagnosis for each newly diagnosed HIV case).

2. Have a Memorandum of Agreement (MOA) for the 5-year funding period in place.

3. Apply geocoding standards provided by CDC, including cleaning and standardizing the data and the collection of variables derived from the geocoding process.

4. Geocode, to the census tract level, residence at HIV disease diagnosis information for cases diagnosed in 2015 per CDC guidance.

Progress narrative for Incidence Surveillance (10 pages) – For each of the “Recipient Activities” below, please provide a narrative description of progress towards achieving the program’s objectives and activities as provided in the FOA 13-1302 application. Please be specific in describing the accomplishment of activities which will lead to the attainment of the related objective. Please use quantitative terms whenever possible to assist us in understanding the quality of your performance.

You must address the following:

1. Collaborate with CDC, laboratories, providers, and affected communities.

2. Obtain HIV testing and treatment information on all newly diagnosed individuals.

3. Collect results from tests for recent HIV infection.

4. Collect all CD4 and viral load results as applicable by local laws and regulations and enter into eHARS.

5. Integrate HIV incidence surveillance activities with case surveillance activities.

6. Report data to CDC.

7. Conduct systematic evaluation of HIV incidence using outcome and process standards.

8. Annually calculate and disseminate population-based estimates of HIV incidence and promote the use of incidence data for prevention and health planning.

9. Collaborate with CDC to revise program design, implementation, and evaluation.

10. Attend CDC-sponsored mandated conferences and workshops consistent with the funded activities.

Adherence to security and confidentiality policies and procedures.

6. Implementation Plan and Timeline for FY 2017 (Proposed Objectives and Activities)

For Case Surveillance, Incidence Surveillance, and Optional Activities for which you applied under FOA PS13-1302, please provide an Implementation Plan and Timeline for Budget Year 5. This plan should:

1. Address all programmatic objectives and activities to be performed during the period January 1, 2017 to December 31, 2017.

2. Be attached in the “Mandatory Documents” box in PDF format under “Other Attachments.”

3. Provide objectives that are designed to successfully achieve all standards for the “Recipient Activity” as established in the Technical Guidance for HIV Surveillance Programs Volume I: Policies and Procedures. Each Objective is to have time-phased activities which are designed to successfully accomplish the related objective. For each objective, indicate the program’s evaluation plan.

For each component, use this format:

Required Activity:

• SMART Objective

• Activities

• Evaluation plan

Special Note: If the program plans to add, remove, or revise a program objective from previously proposed objectives, please clearly identify the changes as a “Proposed New Objective,” “Proposed Revised Objective,” or “Proposed Removed Objective.”

4. Implementation Plan for Case Surveillance (No page Limit) - To prepare for the next budget period for HIV Case surveillance, programs should describe their plan to address defined programmatic objectives and activities in accordance to the technical guidance. Please establish each objective/activity as Specific, Measureable, Action-oriented, Realistic, and Time-phased (SMART). At a minimum, your program should address each requirement listed below with an objective and associated activities.

You must address the following:

1. Identify and report persons with HIV infection.

2. Conduct death ascertainment.

3. Conduct intrastate de-duplication of HIV cases.

4. Participate in routine interstate duplicate review (RIDR) of HIV cases.

5. Conduct risk factor ascertainment.

6. Collect HIV laboratory results.

7. Assess data quality.

8. Investigate cases of public health importance (COPHI).

9. Conduct evaluation of the HIV surveillance system.

10. Conduct analysis of HIV surveillance data and disseminate findings.

11. Report data to CDC.

12. Integrate case and incidence surveillance.

13. Integrate program activities to enhance efficiency and improve outcomes.

14. Attend CDC sponsored meetings.

15. Implement and adhere to data security and confidentiality guidelines.

16. Implement National HIV Surveillance System software requirements.

17. Other Case Surveillance Activities (MHS, PHERS, Geocoding): If the jurisdiction plans on conducting any of these activities as part of Case Surveillance, please describe your plan to address defined programmatic objectives and activities (as listed in F1, F2, and F3 below).

E. Implementation Plan for Incidence Surveillance (No page limits) - To prepare for the next budget period for HIV incidence surveillance, programs should describe their plan to address defined programmatic objectives and activities in accordance to the technical guidance. Your program should address all the requirements listed below with objectives and associated activities. Please establish each objective as Specific, Measurable, Action-oriented, Realistic and Time-phased (SMART).

You must address the following:

1. Collaborate with CDC, laboratories, providers, and affected communities.

2. Obtain HIV testing and treatment information on all newly diagnosed individuals. Expand methods of collecting negative HIV test results for persons with diagnosed HIV infection.

3. Collect results from tests for recent HIV infection. This includes 1) collecting and shipping remnant samples for persons with HIV diagnosed through 2016 for recency testing at the STARHS laboratory, 2) investigating incomplete laboratory reporting of potential acute HIV infection, and 3) reporting results of recent HIV infection as they become available.

4. Collect all CD4 and viral load results as applicable by local laws and regulations and enter into eHARS.

5. Integrate HIV incidence surveillance activities with case surveillance activities.

6. Report data to CDC.

7. Conduct systematic evaluation of HIV incidence using outcome and process standards.

8. Annually calculate and disseminate population-based estimates of HIV incidence and promote the use of incidence data for prevention and health planning.

9. Collaborate with CDC to revise program design, implementation, and evaluation.

10. Attend CDC-sponsored mandated conferences and workshops consistent with the funded activities.

11. Adherence to security and confidentiality policies and procedures.

In addition, CDC requires that additional objectives and activities being conducted by the individual program also be listed in the IPR (e.g., revisions of state reporting regulations, participation in meetings and conference calls as stated in the cooperative agreement, data cleaning, and pilot testing of CDC programs).

F. Implementation Plan for Optional Activities (No page limits) - This section applies only to those awardees that were notified that their original FOA PS 13-1302 Notice of Award that their application for MHS, PHERS or Geocoding was “Approved, but not funded.” Please see the list of grantees (below) that are required to submit an implementation plan for each category. All other grantees should not submit this implementation plan requirement since they will not be reviewed or considered.

1. Implementation Plan for Molecular HIV Surveillance (No page limits):

To be completed by Alabama, Arizona, California, Colorado, Connecticut, Washington DC, Florida, Houston, Idaho, Illinois, Los Angeles, Louisiana, Maryland, Michigan, Montana, New York, New York City, Oregon, Philadelphia, Puerto Rico, San Francisco, Texas, Utah, Virginia, Washington, and Wisconsin.

To prepare for the next budget period for MHS, programs should describe their plan to address defined programmatic objectives and activities in accordance to the technical guidance. Your program should address all the requirements listed below with objectives and associated activities. Please establish each objective as Specific, Measurable, Action-oriented, Realistic and Time-phased (SMART).

MHS Activities:

You must address the following:

1. Secure and confidential reporting of HIV surveillance data.

2. Review state or local HIV laws and regulations regarding the reporting of HIV nucleotide sequence data.

3. Collaborate with laboratories performing HIV genotypic drug resistance testing.

4. Obtain all HIV nucleotide sequence data for persons diagnosed with HIV infection.

5. Validate HIV nucleotide sequence data.

6. Import all nucleotide sequence data into eHARS.

7. Collect antiretroviral use history data for all persons newly diagnosed with HIV infection.

8. Report all data to CDC.

9. Conduct ongoing monitoring of data quality and evaluation of local activities.

10. Analyze data, including transmitted drug resistance.

11. Develop and disseminate data reports and presentations.

12. Attend CDC sponsored meetings.

2. Implementation Plan for Perinatal HIV Exposure Surveillance (No page limits):

To be completed by Alabama, Chicago, Delaware, Washington DC, Georgia, Houston, Illinois, Iowa, Kansas, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, New York, New York City, Oklahoma, Pennsylvania, Philadelphia, Puerto Rico, Rhode Island, Texas, Utah, Virgin Islands, Virginia, Washington, and Wisconsin.

To prepare for the next budget period for PHERS, programs should describe their plan to address defined programmatic objectives and activities in accordance to the technical guidance. Your program should address all the requirements listed below with objectives and associated activities. Please establish each objective as Specific, Measurable, Action-oriented, Realistic and Time-phased (SMART).

PHERS Activities:

You must address the following:

1. Conduct active and passive surveillance for perinatal HIV exposure.

2. Conduct longitudinal follow-up of all HIV exposed children.

3. Conduct medical record review to assess for opportunistic infections.

4. Assess potential adverse outcomes of AVR exposure.

5. Conduct linkage of HIV and birth registries.

6. Conduct active and passive surveillance for HIV-infected pregnant women.

7. Conduct activities to improve the quality efficiency and productivity of perinatal exposure surveillance.

8. Conduct an evaluation of the perinatal HIV surveillance program as defined in the Technical Guidance for HIV Surveillance Programs Volume I: Policies and Procedures document.

9. Report data to CDC.

10. Analyze and disseminate perinatal HIV surveillance data and promote their use for prevention and health services planning and evaluation.

11. Implement and adhere to Data Security and Confidentiality Guidelines.

12. Attend CDC sponsored meetings

3. Implementation Plan for Geocoding and Data linkage (No page limits):

To be completed by Alabama, Arizona, California, Chicago, Colorado, Connecticut, Washington DC, Florida, Georgia, Hawaii, Houston, Illinois, Iowa, Louisiana, Maryland, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New York, New York City, North Carolina, Oklahoma, Oregon, Pennsylvania, Philadelphia, Puerto Rico, San Francisco, Texas, Utah, Virgin Islands, Virginia, Washington, and Wisconsin.

To prepare for the next budget period for geocoding and data linkage, programs should describe their plan to address defined programmatic objectives and activities in accordance to the technical guidance. Your program should address all the requirements listed below with objectives and associated activities. Please establish each objective as Specific, Measurable, Action-oriented, Realistic and Time-phased (SMART).

Geocoding Activities:

You must address the following:

1. Collect HIV surveillance information according to routine surveillance procedures (Required data elements include local street address, city, and state of residence at diagnosis for each newly diagnosed HIV case).

2. Have a Memorandum of Agreement (MOA) for the 5-year funding period in place.

3. Apply geocoding standards provided by CDC, including cleaning and standardizing the data and the collection of variables derived from the geocoding process.

4. Geocode, to the census tract level, residence at HIV disease diagnosis information for cases diagnosed in 2016 per CDC guidance.

5. Report data to CDC.

7. Additional Program Requirements

1. Annual Federal Financial Report (FFR, SF-425): The Annual Federal Financial Report (FFR) SF-425 is required and effective January 1, 2017, it must be submitted hardcopy (previously through eRA Commons) to your Grants Management Specialist and Grants Management Officer no later than 90 days after the end of the calendar quarter in which the budget period ends. The FFR for this budget period is due to the GMS/GMO by March 31, 2017. Reporting time frame is January 1, 2016 through December 31, 2016.

2. Overall Responsible Party (ORP): Each grantee must submit their annual Certification of Compliance with the NCHHSTP Data Security and Confidentiality Standards, Designation of Overall Responsible Party.

3. Standards Evaluation Report (SER): Each grantee must submit their SER and SAS tables to your Epidemiologist and Public Health Advisor only (no need to submit to the Office of Grants Services (OGS; formerly PGO) by January 31, 2017.

Please reference the funding opportunity announcement number and your award number on all correspondence.

The Office of Grants Services (OGS) and the CDC/DHAP/HIV Incidence and Case Surveillance Branch (HICSB) will review the APR for completeness. OGS will provide an analysis of the financial/business portion of the APR and HICSB will provide an analysis of the technical/programmatic portion of the APR. OGS and HICSB will jointly decide whether to award the continuation based on the analysis of all APR documentation, the availability of funds, and the best interest of the government. CDC may withhold an award due to delinquent reports, failure to show satisfactory progress, inadequate stewardship of Federal funds, or failure to meet the terms and conditions of the award. This memo will be a part of the official grant file.

The recipient is reminded that the annual Federal Financial Report (FFR) and the Annual Performance Report (APR) covering budget period January 2016 to December 2016 are due within 90 days from the end of the current budget period. 

Should you have any grants management questions, including questions related to your budget, please contact Constance Jarvis, Grants Management Specialist at (770) 488-5859. Any programmatic questions should be directed to Lydia Blasini-Alcivar at [email protected] or (404) 639-4108.

NOTE:  Certifications and Assurances –Non-Construction forms are required to be submitted with APR application. Please go to the following website: http://wwwn.cdc.gov/grantassurances/Homepage.aspx, to upload the forms.  The forms are required for each year of the project and should be updated as necessary. When you enter the website, click on Download Instructions and Forms and follow the instructions.  To upload the completed forms, click on “Submit Documents” in the upper left of the screen. 

Appendix A: Assurance of Compliance

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.) CDC 0.1113 (E), Rev. 3/1993, CDC Adobe Acrobat 5.0 Electronic Version, 8/2002
NAME	OCCUPATION		AFFILIATION
			(Health Department Representative)
Applicant/Grantee Name:		Grant Number (If Known):
Signature: Project Director		Signature: Authorized Business Official
Date:     		Date:     

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