OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Emergency Epidemic Investigation Data Collections - Expedited Reviews

ICR 201604-0920-011 · OMB 0920-1011 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016 Form and Instruction New Available
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016 Form and Instruction New Available
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016 Form and Instruction New Available
Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016 Form and Instruction New Available
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016 Form and Instruction New Available
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016 Form and Instruction New Available
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016. Form and Instruction New Available
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016 Form and Instruction New Available
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016 Form and Instruction Unchanged Available
Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016 Form and Instruction Unchanged Available
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016 Form and Instruction Unchanged Available
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 Form and Instruction Unchanged Available
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016 Form and Instruction Unchanged Repair queued
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016 Form and Instruction Unchanged Available
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016 Form and Instruction Unchanged Available
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016 Form and Instruction Unchanged Repair queued
EEI Guillain-Barre Syndrome_Bahia Brazil Form Unchanged Available
Undetermined risk factors for ocular syphilis - North Carolina, 2015 Form Unchanged Available
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015. Form and Instruction Unchanged Available
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015 Form and Instruction Unchanged Available
GAS_IL 2015 Form Unchanged Available
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015 Form and Instruction Unchanged Available
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015 Form and Instruction Unchanged Available
PA NTM Form Unchanged Available
Cholera_Kenya Form and Instruction Unchanged Available
Burkholderia Investigation_LA Form and Instruction Unchanged Available
Mucormycosis_Kansas Form and Instruction Unchanged Available
CCRF_Georgia Form Unchanged Available
Ebola_TX Form Unchanged Available
Ebola_West Africa_2014 Form and Instruction Unchanged Repair queued
Pediatric cluster of neurologic symptoms - Colorado Form Unchanged Available
BSI_CA Form Unchanged Available
2014015-XXX_Parechovirus_Multi Form Unchanged Available
2014011-XXX Ebola_Liberia Form Unchanged Available
Form 0920-1011 2014010-XXX Ebola_Guinea Form and Instruction Unchanged Available
2014008-XXX Chikungunya_PR Form Unchanged Available
2014005XXX_DiarrhealDisease_AS Form Unchanged Available
2014004XXX_Legionnaires' Disease_Alabama 2014 Form Unchanged Available
2014E003XXX_MERS-CoV_GA Form Unchanged Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2016-04-27 Available
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2016-04-27 Available
0920-1011 Non-Substantive Change Request Memo_Y2Q4_4-1-2016.docx Justification for No Material/Nonsubstantive Change Uploaded 2016-04-27 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2016-01-27 Available
0920-1011 Non-Substantive Change Request Memo_Y2Q3_Subm 1-22-2016.docx Supplementary Document Uploaded 2016-01-27 Available
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2016-01-27 Repair queued
Appendix 2. Data Collection Forms_0920-1011.pdf Supplementary Document Uploaded 2015-11-03 Available
Appendix 1. Burden Memo_0920-1011.pdf Supplementary Document Uploaded 2015-11-03 Available
0920-1011 Non-Substantive Change Request Memo_Y2Q2_10-01-2015_Subm.docx Supplementary Document Uploaded 2015-11-03 Available
0920-1011 Non-Substantive Change Request Memo_Y2Q1_07-02-2015.docx Supplementary Document Uploaded 2015-07-07 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-07-07 Repair queued
Appendix 1. Burden Memo.pdf Supplementary Document Uploaded 2015-07-07 Available
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2015-04-22 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-04-22 Available
0920-1011 Non-Substantive Change Request Memo_Y1Q4_04-15-2015.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-04-22 Available
0920-1011 Non-Substantive Change Request Memo_Y1Q3_03-02-2015.docx Justification for No Material/Nonsubstantive Change Uploaded 2015-03-03 Repair queued
Appendix 1. Burden Memos.pdf Supplementary Document Uploaded 2015-03-03 Available
Appendix 2. Data Collection Forms.pdf Supplementary Document Uploaded 2015-03-03 Available
2014012-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014010-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014008-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Repair queued
2014007-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014006-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014005-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014004-XXX Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
2014003-XXX_Burden Memo.docx Supplementary Document Uploaded 2014-10-29 Available
Inventory.pdf Supplementary Document Uploaded 2014-10-29 Available
EEI GenICR 0920-1011_Attach E _Burden Memo_9_16_2014.docx Supplementary Document Uploaded 2014-10-29 Available
EEI GenICR 0920-0111_Attach D_Request for Approval 9-16-2014.docx Supplementary Document Uploaded 2014-10-29 Available
EEI GenICR 0920-1011_Attach C_ Steps Conduct Emer Epi Invest_10_20_14.docx Supplementary Document Uploaded 2014-10-29 Repair queued
0920-1011 Non-Substantive Change Request Memo_revised.docx Justification for No Material/Nonsubstantive Change Uploaded 2014-10-29 Available
EEI GenICR_Sup St B_3_20_14.docx Supporting Statement B Uploaded 2014-03-25 Available
EEI GenICR 0920-13ZJ_App 6_Online Survey Case Finding Questionnaire_11-06-2013.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 5_Phone Interview Questionnaire Patient_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 4_Q Fever Person Interview Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 3 _Hantav Pulm Synd Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 2_GBS Case Questionnaire_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_App 1_Chart Abstract Form_11-14-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_Attach H_Biospecimen Storage Consent_11-06-2013_Subm.docx Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR_0920-13ZJ_Attach G _Emer Epi Invest_IRB Letter_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI Gen ICR 0920-13ZJ_Attach F_Epi Invest SORN_11-06-2013.doc Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR 0920-13ZJ_Attach E _Burden Memo_3-20-14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI_Attach D_Request for Approval_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI GenICR 0920-13ZJ_Attach C_ Steps Conduct Emer Epi Invest_3_20_14.docx Supplementary Document Uploaded 2014-03-25 Available
EEI GenICR_0920-13ZJ_Attach B _Emer Epi Invest_Pub 60-day FRN_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI GenICR_0920-13ZJ_Attach A_Auth Legis Emer Epi Invest_11-06-2013_Subm.pdf Supplementary Document Uploaded 2013-11-20 Available
EEI_GenICR_Sup St A_3_20_14.docx Supporting Statement A Uploaded 2014-03-25 Available
IC Document Collections
IC IDCollectionTypeStatusForm
223019 Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016 Form and Instruction New
222856 Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016 Form and Instruction New
222590 Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016 Form and Instruction New
222574 Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016 Form and Instruction New
222478 Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016 Form and Instruction New
221903 Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016 Form and Instruction New
221731 Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016. Form and Instruction New
221388 Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016 Form and Instruction New
220946 Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016 Form and Instruction Unchanged
220781 Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016 Form and Instruction Unchanged
220762 Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016 Form and Instruction Unchanged
220680 Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 Form and Instruction Unchanged
220097 Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016 Form and Instruction Unchanged
220062 Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016 Form and Instruction Unchanged
220061 Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016 Form and Instruction Unchanged
220060 Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016 Form and Instruction Unchanged
219577 EEI Guillain-Barre Syndrome_Bahia Brazil Form Unchanged
219234 Undetermined risk factors for ocular syphilis - North Carolina, 2015 Form Unchanged
219193 Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015. Form and Instruction Unchanged
218903 Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015 Form and Instruction Unchanged
218858 GAS_IL 2015 Form Unchanged
218802 Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015 Form and Instruction Unchanged
217928 Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015 Form and Instruction Unchanged
217651 PA NTM Form Unchanged
217021 Cholera_Kenya Form and Instruction Unchanged
214996 Burkholderia Investigation_LA Form and Instruction Unchanged
214724 Tainted Beverage_Mozambique Other-WORD Unchanged
214409 Mucormycosis_Kansas Form and Instruction Unchanged
214244 Dengue_AZ Other-WORD Unchanged
213373 CCRF_Georgia Form Unchanged
213323 Ebola_TX Form Unchanged
213274 Ebola_West Africa_2014 Form and Instruction Unchanged
213233 Pseudomonas NICU_CA Other-WORD Unchanged
213189 Pediatric cluster of neurologic symptoms - Colorado Form Unchanged
213101 BSI_CA Form Unchanged
212908 2014016-XXX_Ebola_DRC Other-WORD Unchanged
212644 2014015-XXX_Parechovirus_Multi Form Unchanged
212395 2014014-XXX Ebola_Sierra Leone Other-PDF Unchanged
212348 2014013-XXX_Resp Illness UAC_Multi Other-WORD Unchanged
212320 2014012-XXX Resp Illness UC_CA Other-WORD Unchanged
212266 2014011-XXX Ebola_Liberia Form Unchanged
212227 2014009-XXX_Chikungunya_US Service Org Volunteers Unchanged
212127 2014010-XXX Ebola_Guinea Form and Instruction Unchanged
211951 2014008-XXX Chikungunya_PR Form Unchanged
211894 Chikungunya_USVI Other-WORD Unchanged
211760 20140006XXX Measles FSM Other-WORD Unchanged
211705 2014005XXX_DiarrhealDisease_AS Form Unchanged
211702 2014004XXX_Legionnaires' Disease_Alabama 2014 Form Unchanged
211682 2014E003XXX_MERS-CoV_GA Form Unchanged
ICR Details
0920-1011 201604-0920-011
Historical Active 201601-0920-017
HHS/CDC 16AGF
Emergency Epidemic Investigation Data Collections - Expedited Reviews
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 05/02/2016
Retrieve Notice of Action (NOA) 04/28/2016
  Inventory as of this Action Requested Previously Approved
03/31/2017 03/31/2017 03/31/2017
36,000 0 36,000
18,000 0 18,000
0 0 0
CDC submits the quarterly inventory of forms and burden memos per agreement with OMB.
US Code: 42 USC 301 Name of Law: PHSA
  
None
Not associated with rulemaking
  78 FR 41930 07/12/2013
78 FR 69854 11/21/2013
Yes
49
IC Title Form No. Form Name
2014010-XXX Ebola_Guinea 0920-1011, 0920-1011 Appendix 1- Case Investigation Form ,   Appendix 2- Contact Tracing Form
20140006XXX Measles FSM
Pseudomonas NICU_CA
2014012-XXX Resp Illness UC_CA
Mucormycosis_Kansas None, None Infection Prevention and Control Questions for Investigation of Mucormycosis ,   Mucormycosis Data Abstraction Form
Undetermined risk factors for ocular syphilis - North Carolina, 2015 NA, NA Abstraction Form ,   Interview Form
Undetermined source for Salmonella Infantis infections among detention center inmates - South Carolina, 2016 NA Salmonella Infantis Infections among Detention Center Inmates - Case Interview Form
Tainted Beverage_Mozambique
Chikungunya_USVI CDC 56.31 A REV. 06/2006 Dengue Case Investigation Report
2014011-XXX Ebola_Liberia none, none Case Report Form ,   Contact Listing Form
2014014-XXX Ebola_Sierra Leone
BSI_CA none, none, none Chart Abstraction ,   Outpatient Dialysis Practices Survey ,   Reprocessing Observation Checklist
Undetermined risk factors associated with increase in bites from rabid dogs, resulting in at least one human death, Gonaives, Haiti, 2015 NA, NA, NA, NA, NA, NA, NA, NA Community Suyrvey - English ,   Community Survey - French ,   Medical Providers Interview Survey - English ,   Medical Providers Interview Survey - French ,   Rabies Official Interview Survey - English ,   Rabies Official Interview Survey - French ,   Public Health Official Interview Survey - English ,   Public Health Official Interview Survey - French
Undetermined sources and risk factors for a Rift Valley Fever Outbreak-Uganda, 2016 NA, NA Risk Factor Questionnaire ,   Livestock Assessment Form
GAS_IL 2015 NA, NA GAS_IL Medical Record Abstraction ,   GAS_IL Employee Questionnaire
Pediatric cluster of neurologic symptoms - Colorado none, none Medical Chart Abstraction ,   Family Interview Questionnaire
Ebola_West Africa_2014 none, none, none Focus Group Guide ,   Observation Guide ,   Field Guide
Burkholderia Investigation_LA None Risk Assessment for Primate Research Center Employees and Inspectors
Cholera_Kenya None, None Community Questionnaire ,   Healthcare Worker Questionnaire
Qualitative Investigation of HIV Transmission in Southeastern Indiana, 2015 NA HIV Risk Factors Interview Guide
PA NTM none, none Interview Questions ,   Records Abstraction Information
Undetermined Mode of Transmission_Zika Virus among Utah Health Care Providers, 2016 NA Healthcare Professional Risk Assessment Questionnaire
Undetermined risk of exposure for human-to-human spread of rabies to contact of case patient following mongoose-associated human rabies case, Puerto Rico, 2015. NA, NA, NA, NA Community Assessment ,   Community Assessment - Spanish ,   Healthcare Worker Assessment ,   Healthcare Worker Assessment
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Puerto Rico, 2016 NA, NA Zika Virus Disease Case Investigation Form ,   2016 Urgent Assessment of Blood Collection and Use in Puerto Rico in Response to the Zika Virus Outbreak
Undetermined risk factors for Exophiala dermatitidis among oncology patients - New York City, 2016. NA, NA CDC Call Script ,   NYC Healthcare Worker Questionnaire
Undetermined source of Elizabethkingia meningoseptica bloodstream infection among Wisconsin residents - Wisconsin, 2016 NA Elizabethkingia Meningoseptica Case Investigation Form
Undetermined Source of an outbreak of Legionnaires' Disease among Hotel A Visitors - Hannibal, MO 2015 NA, NA Legionella Environmental Assessment Form ,   Sample Data Sheet
2014005XXX_DiarrhealDisease_AS none, none Medical Abstraction Form ,   Case Questionnaire
2014015-XXX_Parechovirus_Multi none, none Chart Abstraction ,   Family interview
2014004XXX_Legionnaires' Disease_Alabama 2014 none, none Record Abstraction ,   Interview Questionnaire
Undetermined agent, source, mode of transmission, and risk factors for Guillain-Barré Syndrome in the setting of Zika virus transmission - Colombia, 2016 NA, NA, NA, NA GBS_Columbia Case Control Investigation Questionnaire - English ,   GBS_Columbia Case Control Investigation Questionnaire - Spanish ,   GBS_Columbia Chart Abstraction Form - English ,   GBS_Columbia Chart Abstraction Form - Spanish
Undetermined transmission and risk factors for multidrug-resistant Mycobacterium tuberculosis among Tribal members - Arizona, 2016 NA, NA, NA Case Abstraction Form ,   Case Interview Form ,   Contact Interview and Abstraction Form
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection - Brazil, 2016 NA, NA Survey Questionnaire ,   Chart Abstraction
Undetermined source of Elizabethkingia anophelis infections among Wisconsin residents - Wisconsin, 2016 NA Focus Group Discussion Guide
Undetermined source and risk factors for botulism among prisoners at a correctional facility - Mississippi, 2016 NA Questionnaire for Prison Outreak of Clostridium Botulinum, June 2016
Undetermined Mode of Transmission_Zika Virus among Utah Community Members, 2016 NA Community Member Questionnaire
Undetermined source, mode of transmission, and risk factors for Hepatitis A virus (HAV) transmission ‒ Hawaii, 2016 NA, NA HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CASE QUESTIONNAIRE ,   HEPATITIS A VIRUS (HAV) OUTBREAK HAWAII, 2016—CONTROL QUESTIONNAIRE
2014009-XXX_Chikungunya_US Service Org Volunteers
CCRF_Georgia none, none, none Case Investigation ,   KAP Survey ,   Consent
EEI Guillain-Barre Syndrome_Bahia Brazil NA, NA, NA, NA Case Control Questionnaire - GBS English ,   Case Control Questionnaire - GBS Portugese ,   Chart Abstraction Questionnaire - GBS English ,   Chart Abstraction Questionnaire - GBS Portugese
Undetermined sources, modes of transmission, risk factors, and health outcomes for Zika virus infection – American Samoa, 2016 NA Zika Virus Disease Case Investigation Form
Undetermined source, mode of transmission, and risk factors for an outbreak of group A Streptococcus among residents of a long term care facility - Chicago, Illinois, 2016 NA, NA, NA Invasive GAS in LTCF 2016 - Employee Survey ,   Investigation of GAS outbreak in LTCF 2016 - Resident Record Extraction Form ,   Invasive GAS in Long Term Care Facility 2016 - Wound Care Survey
Undetermined risk factors for E.coli O157 among visitors to a goat dairy--Connecticut, 2016 NA Festival A Interview Form
2014008-XXX Chikungunya_PR none, none, none, none Household Questionnaire ,   Individual Questionnaire ,   Case Report (English) ,   Case Report (Spanish)
2014016-XXX_Ebola_DRC
Ebola_TX None, None Appendix 1 - Ebola Case Investigation Form ,   Appendix 2 - Ebola Case Contact Questionnaire
2014E003XXX_MERS-CoV_GA none, none Questionnaire for Passengers and Crew ,   Follow-up Questionnaire for Asymptomatic Passengers and Crew
2014013-XXX_Resp Illness UAC_Multi
Dengue_AZ CDC56.31A DENGUE Case Investigation Report
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 36,000 36,000 0 0 0 0
Annual Time Burden (Hours) 18,000 18,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
This is a new generic information collection request.
$1,510,099
Yes Part B of Supporting Statement
No
No
No
No
Uncollected
Shari Steinberg 404 639-4942 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
04/28/2016