**[Attachment XIII:]{.smallcaps}** CDC Form 0.1113: Assurance of
Compliance with the Requirements for Contents of AIDS-Related Written
Materials

+----------------------------+----------+----------+-------------------+
| ![](media/image1.wmf){w    |          |          |                   |
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| ht="0.9305555555555556in"} |          |          |                   |
| **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**                   | **OCCU   |          | **AFFILIATION**   |
|                            | PATION** |          |                   |
+----------------------------+----------+----------+-------------------+
|                            |          |          |                   |
+----------------------------+----------+----------+-------------------+
|                            |          |          |                   |
+----------------------------+----------+----------+-------------------+
|                            |          |          |                   |
+----------------------------+----------+----------+-------------------+
|                            |          |          |                   |
+----------------------------+----------+----------+-------------------+
|                            |          |          | **(Health         |
|                            |          |          | Department        |
|                            |          |          | Representative)** |
+----------------------------+----------+----------+-------------------+
| **Applicant/Grantee        |          | **Grant  |                   |
| Name:**                    |          | Number   |                   |
|                            |          | (If      |                   |
|                            |          | K        |                   |
|                            |          | nown):** |                   |
+----------------------------+----------+----------+-------------------+
| **Signature: Project       |          | **Si     |                   |
| Director**                 |          | gnature: |                   |
|                            |          | Au       |                   |
|                            |          | thorized |                   |
|                            |          | Business |                   |
|                            |          | Of       |                   |
|                            |          | ficial** |                   |
+----------------------------+----------+----------+-------------------+
| **Date:**                  |          | *        |                   |
|                            |          | *Date:** |                   |
+----------------------------+----------+----------+-------------------+

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