**[Institutional Review Board (IRB)]{.smallcaps}**

**[Request for Continuation Approval of Protocol]{.smallcaps}**

**Date Rec'd in HSO** [ ]{.underline}

+-------------------------------------------------------------------------+
| +-----------------------------------------------------------------+---+ |
| | **Instructions**: Use this form when submitting protocols for   |   | |
| | continuing review. Review is required AT LEAST annually;        |   | |
| | however, the IRB may have determined that your protocol will    |   | |
| | need to be reviewed more often. Please submit this form         |   | |
| | electronically along with the current consent form and a copy   |   | |
| | of the protocol (if changed since last year) and any supporting |   | |
| | documents (if changed since last year) to the CIO designated    |   | |
| | staff official. However, if submitted in hardcopy, please send  |   | |
| | the original and three copies all documents to the CIO          |   | |
| | designated official. Consecutively number **ALL** pages,        |   | |
| | beginning with the title page of the protocol (if applicable),  |   | |
| | followed by any consent form(s) and any applicable ancillary    |   | |
| | documents. Complete all applicable items or the form will be    |   | |
| | returned.                                                       |   | |
| +-----------------------------------------------------------------+---+ |
| |                                                                 |   | |
| +-----------------------------------------------------------------+---+ |
|                                                                         |
| **Date Submitted by Investigator:** [ ]{.underline}                     |
+-------------------------------------------------------------------------+

**[Protocol No.]{.smallcaps}** [ ]{.underline}

+-----------------------------------------------------------------+---+
| +----------------------------------------+---+                  |   |
| |   --                                   |   |                  |   |
| |   --                                   |   |                  |   |
| |                                        |   |                  |   |
| | **Title of Protocol: **[ ]{.underline} |   |                  |   |
| +----------------------------------------+---+                  |   |
| |                                        |   |                  |   |
| +----------------------------------------+---+                  |   |
|                                                                 |   |
| Proposed Dates for Project - Begin: [ ]{.underline} End: [      |   |
| ]{.underline}                                                   |   |
+-----------------------------------------------------------------+---+
|                                                                 |   |
+-----------------------------------------------------------------+---+

**Name of CDC Employee Serving as Principal Investigator (PI) and
Degrees:**

  --------------------------- --
  9 Check if PI has changed   
                              
  --------------------------- --

*Scientific Ethics* Verification No.: [ ]{.underline} Telephone: [
]{.underline} Fax: [ ]{.underline}

+----------------------------------------------------------------------+
| +----------------------------------------------------------------+   |
| | +----------------------------------------------------------+   |   |
| | | +----------------------------------------------------+   |   |   |
| | | | +                                                  |   |   |   |
| | | | -------------------------------------------------+ |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  +-----------------------------------------+---+ | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | +-------------------------------+---+   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | +---------------------+---+   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | +-----------+---+   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |   ------  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
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| | | | |                                                  |   |   |   |
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| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | ------ -- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |   **CI    |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | O:** [ ]{ |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | .underlin |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | e} **Divi |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | sion:** [ |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |  ]{.under |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | line} **M |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | S:** [ ]{ |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | .underlin |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | e} Email  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | Address:  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | [ ]{.unde |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | rline}    |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |   ------  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | --------- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | ------ -- |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | **Names   |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | of Other  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | CDC       |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | Employee  |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | Co-inve   |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | stigators |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | (use      |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | sup       |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | plemental |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | page if   |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | \> than   |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | | 3):**     |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | +-----------+---+   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | |           |   |   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | +-----------+---+   |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | |                     |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | 1\. [ ]{.underline} |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | *Scientific Ethics* |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | Verification No.: [ |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | | ]{.underline}       |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | +---------------------+---+   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | |                     |   |   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | +---------------------+---+   |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | |                               |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | 2\. [ ]{.underline}           |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | *Scientific Ethics*           |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | Verification No.: [           |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | | ]{.underline}                 |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | +-------------------------------+---+   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | |                               |   |   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | +-------------------------------+---+   |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  |                                         |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | 3\. [ ]{.underline} *Scientific Ethics* |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  | Verification No.: [ ]{.underline}       |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  +-----------------------------------------+---+ | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  |                                         |   | | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  +-----------------------------------------+---+ | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |                                                  | |   |   |   |
| | | | |                                                  |   |   |   |
| | | |  **1. Current Status**                           | |   |   |   |
| | | | +                                                  |   |   |   |
| | | | -------------------------------------------------+ |   |   |   |
| | | | |                                                  |   |   |   |
| | | |                                                  | |   |   |   |
| | | | +                                                  |   |   |   |
| | | | -------------------------------------------------+ |   |   |   |
| | | |                                                    |   |   |   |
| | | | [ ]{.underline} Study not yet begun (Provide       |   |   |   |
| | | | explanation in item 5. Complete item 8, if         |   |   |   |
| | | | applicable)                                        |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | | |                                                    |   |   |   |
| | | +----------------------------------------------------+   |   |   |
| | |                                                          |   |   |
| | | [ ]{.underline} Active research; contact with subjects   |   |   |
| | | continuing (Complete items 2-10)                         |   |   |
| | +----------------------------------------------------------+   |   |
| | |                                                          |   |   |
| | +----------------------------------------------------------+   |   |
| |                                                                |   |
| | [ ]{.underline} Active research with subjects completed; study |   |
| | activities involve only data analysis and/or report writing    |   |
| | (Complete items 2,5,6,7,8 & 10)                                |   |
| +----------------------------------------------------------------+   |
| |                                                                |   |
| +----------------------------------------------------------------+   |
|                                                                      |
| [ ]{.underline} Study does not involve contact with subjects (e.g.,  |
| research using existing records); study activities involve only data |
| analysis and/or report writing (Complete items 5,6,7,10)             |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**2. Study Population** (If an international study, provide
race/ethnicity of subjects by percentages:

+-----------------------------------------+
|   -- --                                 |
|                                         |
|                                         |
|   -- --                                 |
|                                         |
| [ ]{.underline} Enrolled this past year |
+-----------------------------------------+

**For individuals who were enrolled this year:**

Gender distribution:

+-----------------------------------------------------------------+---+
| +-------------------------------------------------------+---+   |   |
| | +---------------------------------------------+---+   |   |   |   |
| | | +-----------------------------------+---+   |   |   |   |   |   |
| | | |   ----------------                |   |   |   |   |   |   |   |
| | | | --------------------------------- |   |   |   |   |   |   |   |
| | | |   [ ]{.underline                  |   |   |   |   |   |   |   |
| | | | } % Female [ ]{.underline} % Male |   |   |   |   |   |   |   |
| | | |   ----------------                |   |   |   |   |   |   |   |
| | | | --------------------------------- |   |   |   |   |   |   |   |
| | | |                                   |   |   |   |   |   |   |   |
| | | | [ ]{.underline} Total number of   |   |   |   |   |   |   |   |
| | | | subjects to date                  |   |   |   |   |   |   |   |
| | | +-----------------------------------+---+   |   |   |   |   |   |
| | | |                                   |   |   |   |   |   |   |   |
| | | +-----------------------------------+---+   |   |   |   |   |   |
| | |                                             |   |   |   |   |   |
| | | [ ]{.underline} Declined enrollment this    |   |   |   |   |   |
| | | past year                                   |   |   |   |   |   |
| | +---------------------------------------------+---+   |   |   |   |
| | |                                             |   |   |   |   |   |
| | +---------------------------------------------+---+   |   |   |   |
| |                                                       |   |   |   |
| | [ ]{.underline} Withdrawn from project this past year |   |   |   |
| +-------------------------------------------------------+---+   |   |
| |                                                       |   |   |   |
| +-------------------------------------------------------+---+   |   |
| |                                                       |   |   |   |
| +-------------------------------------------------------+---+   |   |
|                                                                 |   |
| **Race/ethnicity distribution of enrolled subjects for domestic |   |
| studies:**                                                      |   |
+-----------------------------------------------------------------+---+
|                                                                 |   |
+-----------------------------------------------------------------+---+

[ ]{.underline} % American Indian or Alaskan Native

[ ]{.underline} % Asian or Pacific Islander

  ---------------------------------------------------------------------
  [ ]{.underline} % Black or African American, not of Hispanic origin
  ---------------------------------------------------------------------

[ ]{.underline} % Hispanic

  -------------------------------------------------
  [ ]{.underline} % White, not of Hispanic Origin
  -------------------------------------------------

**Vulnerable Populations **Have any of these populations been added to
the study? [ ]{.underline} YES [ ]{.underline} NO

  -------------------------------------------- --
  (If **YES**, please check all that apply):   
                                               
  -------------------------------------------- --

[ ]{.underline} Pregnant women (as a SPECIFIC target group)

[ ]{.underline} Fetuses (Ref: 45CFR46, Subpart B)

  -----------------------------------------------------
  [ ]{.underline} Prisoners (Ref: 45CFR46, Subpart C)
  -----------------------------------------------------

[ ]{.underline} Children 17 years of age or younger

(Ref: 45CFR46, Subpart D)

[ ]{.underline} Mentally disabled

  -------------------------------------------------------------
  [ ]{.underline} Educationally or economically disadvantaged
  -------------------------------------------------------------

**3. Collaborating Sites **(Use additional sheets if necessary)**:**

3a. List any collaborating sites by name and location (including state)
that were added since last continuation

+--------------------------------------------------------------------+---+
| +------------------------------------------------------------+---+ |   |
| | +----------------------------------------------------+---+ |   | |   |
| | | +--------------------------------------------+---+ |   | |   | |   |
| | | | +------------------------------------+---+ |   | |   | |   | |   |
| | | | | +--------------------------------+ |   | |   | |   | |   | |   |
| | | | | | +----------------------------+ | |   | |   | |   | |   | |   |
| | | | | | |   ----------- --           | | |   | |   | |   | |   | |   |
| | | | | | |   approval:                | | |   | |   | |   | |   | |   |
| | | | | | |                            | | |   | |   | |   | |   | |   |
| | | | | | |   ----------- --           | | |   | |   | |   | |   | |   |
| | | | | | |                            | | |   | |   | |   | |   | |   |
| | | | | | | [ ]{.underline} None added | | |   | |   | |   | |   | |   |
| | | | | | +----------------------------+ | |   | |   | |   | |   | |   |
| | | | | |                                | |   | |   | |   | |   | |   |
| | | | | | **OPRR Assurance No.:**        | |   | |   | |   | |   | |   |
| | | | | +--------------------------------+ |   | |   | |   | |   | |   |
| | | | | |                                | |   | |   | |   | |   | |   |
| | | | | +--------------------------------+ |   | |   | |   | |   | |   |
| | | | |                                    |   | |   | |   | |   | |   |
| | | | | 1\.                                |   | |   | |   | |   | |   |
| | | | +------------------------------------+---+ |   | |   | |   | |   |
| | | | |                                    |   | |   | |   | |   | |   |
| | | | +------------------------------------+---+ |   | |   | |   | |   |
| | | |                                            |   | |   | |   | |   |
| | | | 2\.                                        |   | |   | |   | |   |
| | | +--------------------------------------------+---+ |   | |   | |   |
| | | |                                            |   | |   | |   | |   |
| | | +--------------------------------------------+---+ |   | |   | |   |
| | |                                                    |   | |   | |   |
| | | 3\.                                                |   | |   | |   |
| | +----------------------------------------------------+---+ |   | |   |
| | |                                                    |   | |   | |   |
| | +----------------------------------------------------+---+ |   | |   |
| |                                                            |   | |   |
| | 4\.                                                        |   | |   |
| +------------------------------------------------------------+---+ |   |
| |                                                            |   | |   |
| +------------------------------------------------------------+---+ |   |
|                                                                    |   |
| 5\.                                                                |   |
+--------------------------------------------------------------------+---+
|                                                                    |   |
+--------------------------------------------------------------------+---+

3b. List any collaborating sites by name and location (including state)
that were deleted since last continuation

+----------------------------------------------------------------------+
| +-                                                                   |
| -------------------------------------------------------------------+ |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
| | +----------------------------------------------------------+   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | | | +-                                                 |   |   | | |
| |                                                                    |
| | | | -------------------------------------------------+ |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | +----------------------------------------------+ | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +-                                           | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------+ | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +----------------------------------------+ | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | +----------------------------------+   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | +----------------------------+   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | +----------------------+   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | +----                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ---------------+---+ |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | +--                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ---------+---+ |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | table>   |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tbody>   |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
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| |                                                                    |
| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | c                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | la       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | s                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | s="odd"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | | | d                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ><table> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tbody>   |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
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| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | | | <                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | c                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | la       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | s                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | s="odd"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | | | d                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ><table> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| |                                                                    |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | tbody>   |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | c                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | la       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | s                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | s="odd"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | | | <                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | | | d                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ><table> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | tbody>   |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | | | c                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | la       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | s                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | s="odd"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| |                                                                    |
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| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | t        |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | d                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ><table> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | | | <                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tbody>   |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | | | <                |   |   |   | | | | |   |   | | |
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| | | | | |                                            | | |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | | c                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | la       |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | | | s                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | s="odd"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
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| | | | | | | | | p>2.     |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | td></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | td></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | p>3.     |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
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| | | | | | | | | /p></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | td></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | /tr>     |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | tr       |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | ="even"> |   | |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
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| | | | | | | | | td></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | td></td> |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | | |                  |   |   |   | | | | |   |   | | |
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| | | | | | | | | | | 4                |   |   |   | | | | |   |   | | |
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| | | | | | | | | \.       |   | |   | |   |   |   | | | | |   |   | | |
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| | | | | | | | | | +--                |   |   |   | | | | |   |   | | |
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| | | | |                                                  |   |   | | |
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| | | | | | | | | ---------+---+ |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
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| | | | | | | | | | |                  |   |   |   | | | | |   |   | | |
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| |                                                                    |
| | | | | | | | | | +--                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ---------+---+ |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | |                    |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | |                |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | | 5\.                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | |                |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | +----                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ---------------+---+ |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | |                    |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | |                |   | |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | +----                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | ---------------+---+ |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | |                      |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | **[4.                |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | Fu                   |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | nding]{.smallcaps}** |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | | (check one):         |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | +----------------------+   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | |                      |   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | +----------------------+   |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | |                            |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | [ ]{.underline} PGO        |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | | Funding Mechanism Used:    |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | +----------------------------+   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | |                            |   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | +----------------------------+   |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | |                                  |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | [ ]{.underline} Cooperative      |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | Agreement No(s).: [              |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | | ]{.underline}                    |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | +----------------------------------+   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | |                                  |   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | +----------------------------------+   | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                        | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | [ ]{.underline} Contract No(s).: [     | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | | ]{.underline}                          | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +----------------------------------------+ | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                        | | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +----------------------------------------+ | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | |                                            | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | [ ]{.underline} Grant: [ ]{.underline}     | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +-                                           | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------+ | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | |                                            | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | |                                            | | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | +-                                           | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | -------------------------------------------+ | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | |                                              | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | [ ]{.underline} Purchase Order (a.k.a.       | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | | Simplified Acquisition):                     | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | +----------------------------------------------+ | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | |                                              | | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | +----------------------------------------------+ | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | |                                                  | |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | | [ ]{.underline} Other funding mechanism:         | |   |   | | |
| |                                                                    |
| | | | +-                                                 |   |   | | |
| |                                                                    |
| | | | -------------------------------------------------+ |   |   | | |
| |                                                                    |
| | | | |                                                  |   |   | | |
| |                                                                    |
| | | |                                                  | |   |   | | |
| |                                                                    |
| | | | +-                                                 |   |   | | |
| |                                                                    |
| | | | -------------------------------------------------+ |   |   | | |
| |                                                                    |
| | | |                                                    |   |   | | |
| |                                                                    |
| | | | [ ]{.underline} Memorandum of Understanding (MOU)  |   |   | | |
| |                                                                    |
| | | | (With whom): [ ]{.underline}                       |   |   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | | |                                                    |   |   | | |
| |                                                                    |
| | | +----------------------------------------------------+   |   | | |
| |                                                                    |
| | |                                                          |   | | |
| |                                                                    |
| | | [ ]{.underline} Interagency Agreement (IAA) (Name of     |   | | |
| |                                                                    |
| | | other agency): [ ]{.underline}                           |   | | |
| |                                                                    |
| | +----------------------------------------------------------+   | | |
| |                                                                    |
| | |                                                          |   | | |
| |                                                                    |
| | +----------------------------------------------------------+   | | |
| |                                                                    |
| |                                                                | | |
| |                                                                    |
| | [ ]{.underline} Other (Specify type and with whom): [          | | |
| |                                                                    |
| | ]{.underline}                                                  | | |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
| |                                                                | | |
| |                                                                    |
| +----------------------------------------------------------------+ | |
| |                                                                    |
|                                                                    | |
| |                                                                    |
| [ ]{.underline} Only CDC investigators performing study            | |
| +-                                                                   |
| -------------------------------------------------------------------+ |
| |                                                                    |
|                                                                    | |
| +-                                                                   |
| -------------------------------------------------------------------+ |
|                                                                      |
| [ ]{.underline} Collaborative (Non-CDC investigators & CDC           |
| investigators; no funding involved)                                  |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**5. Summary of Activities to Date** (Use additional sheets as
necessary):

  --
  --

**6. Summary of Study Modifications Reviewed and Approved This Past
Year** (Use additional sheets as necessary):

[ ]{.underline} None

  --
  --

**7. Summary of Any New Literature, Findings, or Other Relevant
Information** (Use addition sheets as necessary):

[ ]{.underline} None

  --
  --

**8. ** **Summary of Adverse Events or Unanticipated Problems** (Use
additional sheets as necessary):

[ ]{.underline} None

+----------------------------------------------------------------------+
|   --                                                                 |
|   --                                                                 |
|                                                                      |
| **9. Consent Documents** (Attach a copy of each current consent      |
| form, telephone consent text, and/or consent letter):                |
+----------------------------------------------------------------------+
|                                                                      |
+----------------------------------------------------------------------+

**10. Summary of Remaining Activities** (Use additional sheets as
necessary):

+-------------------------------------------------------+
| +---------------------------------------------------+ |
| | +-----------------------------------------------+ | |
| | |   --                                          | | |
| | |   --                                          | | |
| | |                                               | | |
| | | **Approvals** (Signature and Position Title): | | |
| | +-----------------------------------------------+ | |
| |                                                   | |
| | **Date:**                                         | |
| +---------------------------------------------------+ |
|                                                       |
| **Remarks:**                                          |
+-------------------------------------------------------+
|                                                       |
+-------------------------------------------------------+

Branch Chief:

  -- -- --
        
        
  -- -- --

Division Director:

  -- -- --
        
        
  -- -- --

CIO Human Subjects Contact:

  -- -- --
        
  -- -- --