I. BASIC PROGRAM INFORMATION Attachment 1 Program Draw the Lrne/Respect the L/ne by ETR Assocrates Name 2 Federal EIN or Social Secunty Number 3 Content Strands Covered 4 Date SRP Formed 5 Grade Levels 6 Service Area Content strands covered in Draw the Llne are Dlsease Preventlon and Control Drug Abuse Preventlon Famlly Lnfe Personal Health and Mental Health Please the date (month year) In you dellvered supplemental resource to schools ETR Assoclates was rn June of 1981 and has been products and for over 30 ears Please the grade levels of your program(s). Draw the Lme/Respect the Line IS a three-year evldence-based plus curnculum for students In 6 7 and 8* grades Please the d|str|ct(s) and school(s) nn you are currently products and equlpment D|str|ct(s) School(s)' of Publlc Schools Harnsburg Clty School Publlc Schools Clty Schools Lawrence County School Pike County Cooperatlve Extenslon San Unlfled School Pajaro Valley Unlfled School Anchorage School DISIITICII Lauderdale County BOE Los Angeles Unlfled School D|str|ct Los Angeles COE San Bernardlno COE Corona Norco Unatled School Valley Unlfled School Tulare COE Bakersfleld Cnty School Sunnyvale School Alameda COE San Jose Unltled School Santa Clara COE DC Harnsburg PA MA TN Monticello MS Magnolla MS San CA CA Anchorage AK Florence AL Los Angeles CA Downey CA San Bemardlno CA Norco CA Valley CA Vlsalla CA Bakersfleld CA Sunnyvale CA Hayward, CA San Jose, CA San Jose-all Orange County Public Schools Broward County School Board Pinellas County School Board Gwinnett County Public Schools Chicago Public Schools Boston Public Schools Prince George Cnty PS Baltimore County Public Schools Frederick County Public Schools Detroit Public Schools Orange County Schools Chapel Carrboro City Schools Lincoln Public Schools Kearney Public Schools Jersey City Public Schools Trenton Board of Education New York Department of Education Eastern Suffolk BOCES Syracuse City School District Toledo Public Schools Metro Nashville Public Schools Texas Ed SSFVICSS Center Region 8 Arlington ISD Houston ISD San Marcos Consolidated ISD Texas Education Agency El Paso ISD Alexandria City Public Schools Spokane Public Schools Waukesha School District Milwaukee Public Schools Contra Costa Unified School District Mt Diablo Umtied School District Soquel Union Elementary SD Live Oak School District San Lorenzo Valley USD Oakland Unified School District Berkeley County School District Cleveland County Schools Alternative Learning Pasadena Unified School District Richland Count School District Orlando, FL Fort Lauderdale, FL Largo, FL Suwanee GA Chicago IL Grove Hall MA Oxon Hill MD Baltimore MD Frederick MD Detroit Ml Hillsborough NC Chapel Hill NC Lincoln NE Kearney NE Jersey City NJ Trenton NJ New York NY Medford NY Syracuse NY Toledo OH Nashville TN Mount Pleasant TX Arlington TX Houston TX San Marcos TX Austin TX El Paso TX Alexandria VA Spokane WA Waukesha WI Milwaukee WI Pleasant Hill CA Concord CA Soquel CA Santa Cruz CA Felton CA Oakland CA Moncks Corner SC Shelby NC Council Bluffs IA Pasadena CA Columbia SC San Antonio ISD San Antonio, TX Geographic Setting 8 Type of Organization Instructional Delivery Check the sett|ng(s) in which you have provided services to schools in the past v' Urban Rural Suburban Check the sett|ng(s) in which you are prepared to provide services to schools in the future Urban Rural Suburban Check the category that best describes your organization For profit Not for Profit Governmental Ent|ty Institution of Higher Learning Educational Ent|ty Other (describe) (i classroom instruction on-line/Web based etc Draw the Line/Respect the Line is a classroom based program The program consists of 19 lessons Each lesson is 45 60 m|nutes Grade 6 has 5 lessons Grades 7 and 8 have 7 lessons each Draw the Line/Respect the Line includes 3 teachers guides one for each ofthe targeted grades (6 7 and 8) Each teacher guide includes teacher instructions and masters for all student activity sheets Both Spanish and English versions of student 9. Mode of Please describe the methods by which your program delivers instruction to students 10. Provider Contact information 11 Program Description activit sheets are included. Contact Person's Name (Services): Coleen Cantwell, MPH Contact Person's Name (Products): Nancy Gonzalez-Caro, Street Address: 4 Carbonero Way City: Scotts Valley State: Phone (Services) (831) 440-2186 Phone (Products) (831) 440 2237 Fax (831)438-4284 Email (Services) coleenc@etr org Email (Products) gonn@etr org Web Site etr org/pub Hours of eration 6 3 am 5 00 ST Provide a ve|'y brief (3 sentences maximum) description of your program offerings that schools could use in their compliance with the House Bill 999 Draw the Line/Respect the Line published by ETR Associates is a three year evidence based abstinence plus curriculum that provides students in grades 6 7 and 8 the knowledge and skills to prevent HIV other STD and pregnancy Grade 6 emphasizes non sexual situations in which youth may experience pressure in Grade 7 pressures regarding sexual intercourse are considered and in Grade 8 the lessons offer practice in refusal skills in dating situations and a condom mini lecture The curriculum also includes activities for students to do with their families . . . . . Please Also indicate which ke words best match our ro ram offenn Classroom instruction Evidence-based abstinence plus curricula Classroom activities interactive group discussions, roleplays demonstrations speakers Training Interactive skills-based trainings of educators and trainings of trainers Equipment Chart paper markers tape 3x5 index cards student name tents optional DVDs for 7* and 8* grade You may suggest additional keywords that might be included in a searchable database of providers ETR Associates Evidence based curricula Pregnancy prevention HIV and AIDS Abstinence plus Skills based trainings Teaching assistance Program evaluation Please provide a sample of program offerings (e curriculum training agenda sample assessment) See Appendix 1 for a Sample Training Agenda and Appendix 2 for Curriculum Lesson by Lesson Outline aw the Line/Respect the Line rs based on numerous principles Not having sex is the healthiest sexual limit for students in middle school Students can set sexual limits Students can be motivated to maintain their limits Students will encounter challenges to maintain their limits Students can overcome challenges to their limits Students who respect the limits of others will be less coercive Each student has unique needs and condom use is essential protection for those who are sexuall active ATTACHMENT II. INDICATORS OF QUALITY The following measures will allow the Mississippi Department of Education to determine the quality of services you provide. Directions: Shaded upper box is a description of what is required; the lower box contains questions to be answered. A. Evidence of Effectiveness (Limit 2 pages) The proposal will be evaluated based on the extent to which you are able to clearly and specifically show your program's evidence of effectiveness and/or medical accuracy to at least two or more of the indicators listed below. Please cite all sources of evidence. lf yours is a newly developed program, you will not have a record of effectiveness to draw upon. We will weigh heavily the indicators in Part B. Offerors must provide evidence of effectiveness and/or medical accuracy that fall into at least two or more of the cate ories below in order to be a proved. information is provided below showing evidence of effectiveness in Categories 'l and 2. 1. Provide evidence that your program has a positive impact on students' ability to gain information to develop positive attitudes, behaviors and skills necessary to make health-enhancing decisions that are age and developmentally and apply skills responsibly for a lifetime (Cite available research studies). Evaluation--Research Design In the research study, 19 schools were randomly assign-ed to either receive the curriculum, or continue with usual classroom activities regarding HIV, other STD and pregnancy prevention. Ten schools received the curriculum, provided by specially trained family life educators. Pilot Testing Students in focus groups provided information about how youth think and feel about sex, as well as feedback about lesson ideas. Each lesson activity was tested initially in schools not formally part of the study. Then various activities were revised, and additional piloting of the lessons occurred. Finally, full sets of lessons for each grade were taught at or more classrooms in another school district, and final revisions were made. Student feedback was used throughout the process to improve the lessons and make them enjoyable. Data Gathering Active written parental consent and student assent were required for survey participation. 90% of students (3765/4164) in the study schools at baseline returned parental consent forms; 2898 of these parents consented to allow their children to complete the survey. Of these students, 2829 completed the baseline survey (68% of all students). Response rates for the and grade follow- up sun/ey was lower The evaluation of the curriculum involved surveying students in the 19 study schools who had received parental consent to participate in the study. Surveys were completed before students received the program in grade 6, and at the end of grades 7, 8 and 9. Findings Boys who received Draw the Line/Respect the Line were significantly less likely than boys in the comparison group to initiate sex, had significantly greater knowledge, perceived fewer peer norms 6 supporting sex, had more positive attitudes toward reasons for not having sex, had stronger sexual limits, and put themselves in fewer situations that could lead to sexual behaviors. There were no significant differences for girls except regarding peer norms. Girls receiving the curriculum perceived fewer peer norms supporting sex than girls in the comparison group. The surveys indicated that almost 30% of girls in the study in grade 8 had a boyfriend 2 or more years older, and that these girls were more likely to report having had sex. lt's possible that more instruction on the influence of older boyfriends on sexual behaviors, and more skill practice in handling potential power differentials and possible coercion, may help improve the results for girls. and Behavioral Determinants Boys in the intervention group: exhibited significantly greater and condom-related knowledge than control students; had more positive attitudes toward not having sex; perceived fewer peer norms supporting sex; had stronger sexual limits, and were less likely to place themselves in situations that could lead to sexual behaviors. Girls in the intervention group: showed significantly greater HIV and condom knowledge than control students; perceived fewer peer norms supporting sexual intercourse; reported significantly fewer incidents of unwanted sexual advances at the eighth-grade follow- ML Selected References Coyle K, Kirby D, l\/larin B, Gomez C, Gregorich S. 2004. Draw the LinelRespect the Line: A Randomized Trial of a Middle School Intervention to Reduce Sexual Risk Behaviors. American Journal of Public Health. 94 (5): 843-851. 2. Provide letters of reference from previous clients (schools, districts, students, teachers, etc.) offering testimonial information on the positive impact of your program. Provide contact information, start and end dates of service provided, and school and school district name for each reference. (Submit a minimum of 5 letters and a maximum of 10.) Letters of reference with testimonials on the positive impact of the Draw the Line program can be found in Appendix 3. 3. Provide additional evidence of improved outcomes, such as student attendance, retentionlpromotion rates, graduation rates, andlor student behaviorldiscipline. (Cite available research studies). Not applicable. 7 page) The proposal will be evaluated based on the extent to which you are able to clearly and specifically describe your program connection to the Mississippi Curriculum Frameworks for Comprehensive Health and d|strict(s) instructional program(s) Your description should address both of the following indicators. . B. Connection to State Academic Standards and Districts Instructional Programs (Limit 1 1. Describe your program's connection to specific 'competencies in the Mississippi curriculum Frameworks for comprehensive health. Please cite the specific competencies the program addresses. The competencies addressed by Draw the Line, Grades 6-8, are listed below. Locations are listed by Activity. Grade 6: Competency 1: Comprehend concepts related to health promotion and disease prevention. Objective a. Analyze how health education and promotion benefits individuals reduces number of doctor visits, premature deaths, and chronic illness). Location: Activities 1.3, 1.4, 1.5. Competency 3: Demonstrate the ability to practice health-enhancing behaviors and reduce health risks. Objective a. Express personal feelings associated with making good or poor health related decisions. Location: Activities 1.3, 1.4, 1.5. Competency 5: Demonstrate the ability to use interpersonal communication skills to enhance health. Objective a. Demonstrate strategies to manage conflict in healthy ways. Location: Activities 2.3, 2.4, 2.5, 2.6. Objective c. Examine howto handle diflicult interpersonal situations through effective communication. Location: Activities 2.3, 2.4, 3.3, 3.4, 4.3, 4.4, 4.5, 5.4, 5.5, 5.6. Competency 6: Demonstrate the ability to use goal-setting and decision-making skills to enhance health. Objective a. Understand positive and negative reinforcement and how they relate to decision- making. Location: Activities 3.2, 3.3, 4.4, 4.5, 4.6. Grade 7: Competency 1: Comprehend concepts related to health promotion and disease prevention. Objective a. Identify behaviors for effectively handling negative peer pressure and stress. Location: Activities 1.3, 1.4, 1.5, 2.3, 3.3, 3.4, 4.5, 6.3, 6.4, 7.4. Competency 2: Demonstrate the ability to obtain valid health information. Objective b. Distinguish between advertisements and medical information. Location: Activities 5.6, 6.1. Competency 3: Demonstrate the ability to practice health-enhancing behaviors and reduce health risks. Objective a. Demonstrate practices for making safe choices. Location: Activities 4.5, 7.3, 7.4. Competency 4: analyze the influence of culture, media, technology, and other factors on health. Objective d. Examine how information from peers influences health. Location: Activities 2.3, 4.5, 6.3, 6.4. Competency 5: Demonstrate the ability to use interpersonal communication skills to enhance health. Objective c. Demonstrate refusal and negotiation skills to enhance health. Location: Activities 3.4, 4.5, 6.4, 7.4. Competency 6: Demonstrate the ability to use goal-setting and decision-making skills to enhance health. 8 Objective a. Apply strategies and skills needed to attain goals that will contribute to a healthy lifestyle. Location: Activities 3.4, 4.3, 4.4, 4.5, 6.4, 7.4. Objective b. Describe how personal health goals are influenced by changing information, abilities, priorities, and responsibilities. Location: Activities 2.3, 3.3, 3.4. Grade 8 Competency 1: Comprehend concepts related to health promotion and disease prevention. Objective d. Identify ways individuals can reduce risk factors related to communicable and chronic diseases. Location: Activities 1.3, 1.4, 2.3, 2.4, 2.6, 5.3, 6.3, 6.4, 7.3. Competency 4: Analyze the influence of culture, media, technology and other factors on health. Objective c. Understand the relationship between peer association and health decisions. Location: Activities 3.3, 3.6, 4.3. Competency 5: Demonstrate the ability to use interpersonal communication skills to enhance health. Objective b. Practice refusal skills for risk-taking behaviors. Location: Actitity 4.4. Competency 6: Demonstrate the ability to use goal-setting and decision-making skills to enhance heahh. Objective b. Identify factors that influence individual decisions during adolescence. Location: Activities 3.3, 3.4, 3.5. Objective c. Develop a plan that addresses commitment and self-control. Location: Activities 1.3, 1.4, 3.5, 4.3, 7.4. 2. Describe your program's connection with the instructional program(s) of the Mississippi school district(s). Draw the Line emphasizes that avoiding sexual intercourse (and the situations that lead to it) in middle school and beyond protects students from STD and pregnancy, as well as from the social, emotional and health consequences of early intercourse. The curriculum asks students to decide on their personal limits, and gives them the experience of having a limit and maintaining it in the face of pressure. Students' interpersonal skills are developed through the use of roleplays and other skills practice. Monitoring of Student Progress 1 page) The proposal will be evaluated based on the extent to which you clearly describe the specific programs and practices you use to diagnose a student needs prescribe an instructional program to meet that student needs and evaluate and mon|tor student progress towards clearly identified goals Your description should address all three of the following indicators Descr|be the specific process you use to assessldiagnose student needs identify or knowledge gaps and prescribe an instructional program based on the student individual needs 2 Descr|be the specific process you use to evaluate mon|tor and track student progress on a continuous and regular basis 3 Descr|be how you develop a timetable for each student achievement gam that includes clear goals for the student years, ETR has been at the forefront of developing, implementing, evaluating and disseminating evidence-based programs in schools and communities. ETR's Research Department, in particular, is widely recognized for its work in both developing and evaluating sex-related evidence- based education school programs. In addition, we have over 30 years of experience providing technical assistance and training to funded grantees, both regionally and nationally, in the implementation and evaluation of evidence-based programs in several large school districts and communities, including grantees across the nation funded by the Centers for Disease Control and Prevention. ETR is well versed in the content areas being addressed by this RFP as well as general and evaluation-related services and capacity building. We have the experience of customizing pre and post test to measure how change in knowledge, skills, attitude and behavior for sex-related evidence based programs. In addition, for many years we have worked with teachers and schools to assist in understanding and maximizing the use of our evaluation services and findings. For example, The Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health (DASH) contracted with ETR Associates to provide rapid evaluation technical assistance to agencies implementing innovative health programs. ln our work for the California Office of Family Planning, we have developed a continuous program improvement tool kit and provide evaluation support through sen/ing as evaluation liaisons and providing training) to over 100 funded health agencies. In both projects, TA has included assistance in the development of customized evaluation plans, data collection, data analysis and and dissemination of findings. ETR is currently one of three contracted agencies funded by the federal Family Youth and Service Bureau to provide program and evaluation technical assistance to states funded under the Personal Responsibility Education Program (PREP). This project has included the development and implementation of evaluation- related webinars and training sessions. Furthermore, we are currently funded through CDC, Division of Prevention (DHAP), Capacity-Building Branch to provide capacity-building assistance to local CDC-funded community-based organizations implementing prevention programs as well to other CDC-funded capacity-building agencies. Finally, ETR has designed and implemented numerous evaluations of health-related programs in schools and communities across the country. Knowledge surveys are available for each grade level of Draw the Line. The Draw the Line Student Knowledge Surveys are instruments that classroom teachers can use to examine whether short-term knowledge learning objectives have been met among students. A pretest-posttest assessment design can be used to measure pre-instruction levels and post-instruction changes in student learning. I Ability to detect student change using this survey may vary and can be affected by numerous factors number and content of lessons students receive, student scores at pretest, student motivation and interest in topic and survey, etc.) 10 Improvement on the Draw the Line Student Knowledge survey between pretest and posttest can be viewed as supportive, but not definitive, evidence of the curriculum's impact on short- term knowledge learning objectives. A well-designed evaluation study using a strong experimental design with a well matched comparison group and adequate sample size) with more extensive measurement would be needed to provide stronger evidence of curriculum impact. Many of the questions in the Draw the Line Student Knowledge originate from published studies. The language used in some of the questions and/or response options has been modified from the original versions. Some questions have been newly developed for inclusion in this instrument. Please note that these measures may not prove to have adequate reliability, validity, and sensitivity to change for your students and should be pilot tested with your population and setting before use. Even though ETR does not typically work on projects that require developing an individual timetable to track student's achievements and goals, we do have substantial experience in evaluation and monitoring student progress. This experience will make it possible to repurpose these tools to create student timetables that can easily be used by teachers and other school personnel. ll D. Financial and Organizational Capacity (Limit 1 page) The proposal will be evaluated based on the extent to which you offer strong evidence of your capacity to deliver quality services over time to the identified population. You may use the following as sources of evidence: 9 Copies of business license or formal documentation of legal status with respect to conducting business in the state if applicable 9 Contracts, warranties, or guaranties for services provided 9 Proof of liability insurance (company name and policy number, or a copy of the policy cover page) 9 A description of how the provider currently receives funds grants, fees-for-service, etc.) 9 Audited financial statements 9 Credit ratings from an independent rating agency 9 Business plans or profiles that might include: goals, timelines, and expected outcomes; detailed action steps; descriptions of financial and staff resources; organizational budgets that account for revenues and expenses and cash flow activity; and outlines of roles and responsibilities of staff within the organization 9 Descriptions of an experienced management team CEO, CFO, COO. Marketing Director, Director of Staff Development, etc.) and senior staff members who help set direction and maintain a leadership system 9 Samples or descriptions of formal contracts, data collection, accounting, and communications processes and systems. Description should address No. 1 below (financial stability) and at least one additional indicator from this category. 1. Submit evidence demonstrating that your organization is financially sound. Your evidence may include: a description of how you currently receive funds grants, fees-for- service, etc.); audited financial statements; credit ratings from an independent rating agency; organizational budgets that account for revenues, expenses and cash flow activity; andlor proof of liability insurance. (Include company name and policy number, or a copy of the .policy cover pa_ge). ETR Associates (ETR), a national non-profit organization located in CA, has nearly three decades of experience in developing, evaluating and disseminating evidence-based programs designed to prevent teen pregnancy, STD and HIV. For over 30 years, ETR has worked to build capacity to effectively implement evidence-based prevention programs at the local, regional and national levels with schools, community based providers and state and local health and education agencies through the provision of training and technical assistance, evaluation services and publications. Over the past three years, ETR has managed between 30 - 35 active projects totaling over $11 million annually. Project budgets range from $5,000 to $2 million. ETR is also the largest non-profit health education publisher in the U.S. ETR's Publishing Division reaches hundreds of thousands of health professionals annually. ETR ships approximately eight million books and pamphlets worldwide every year. ETR receives funding through grants and contracts and sales of products from federal, state and local government agencies as well as private foundations, non-profit and for profit organizations. Total agency revenue for fiscal year 2008-2009 exceeded $15 million. ETR supports and maintains 114 employees located in four offices across California, and an office in Washington, D.C. as well as telecommuters across the nation with appropriate information technology, administrative, and fiscal management systems. With the use of telephone, fax and ETR's Microsoft Exchange 2007 email system as well as the Microsoft Office SharePoint Sen/er 2007 for collaboration, off-site staff have ready access to agency information, resources and support personnel. ETR utilizes a combination of a fully automated financial reporting system, complimented by auxiliary contract analysis with the use of Excel spreadsheets and the Project Support System to ensure reporting deadlines are met, reports are accurate and address any funder specific requirements on an award by award basis. Each contract/grant awarded to ETR is assigned a unique number within the financial system in order to accurately segregate costs to individual awards '12 according to Generally Accepted Accounting Principles. ETR maintains all original documentation and has in place formal approval processes for purchases, travel and the use of outside consultants. As depicted on the organizational chart, the above infrastructure provides support to the office of the Chief Executive Officer/Chief Operating Officer (CEO), as well as ETR's two divisions, Publishing and Programs Services, which contains two departments and two centers. ETR's Board of Directors is composed of national representative from health and education the meet quarterly in-person with more frequent executive committee meetings via teleconference. ln addition to the above description, we include the following attachments as further evidence of ETR's financial and organizational capacity: Appendix 4: ETR Organizational Chart Appendix 5: Audited Financial Reports 2009-2010 Appendix 6: Nonprofit Certification Appendix 7: Sample Training Contract Appendix 8: Proof of Liability Insurance 13 BU DGETICOST SUMMARY Attachment Applicant SRP Name: Draw the Line/Respect the Line published by ETR Associates Provide an average per pupil cost, per unit of service. (Please describe the length and cost ofa typical unit of service one hour, one month, one semester, one year, etc.). This page may be duplicated as needed. DESCRIPTION OF SERVICE Draw the Line/Respect the Line consists of 19 lessons: Grade 6 has 5 lessons Grades 7 and 8 have 7 lessons each Draw the Line/Respect the Line includes 3 teachers guides one for each of the targeted grades (6 7 and 8) Each teacher guide includes teacher instructions and masters for all student activity sheets Both Spanish and English versions of student activity sheets are included ETR Associates also provides free downloads of pre and post tests on our website at etr org/tppl/products/drawTheL|ne ideally teachers providing Draw the Lrne/Respect the L/ne will receive training regarding the curriculum ETR offers training through its Center for Sexual and Reproductive Health The standard Draw the Line training is 3 days ETR can also provide technical support on ada tation and evaluation of the curriculum COST The 3-grade curriculum may be purchased for $21 per grade for grades 6 and 7; and $40.00 for grade 8 Program sets with supplemental materials to enhance student learning include DVDs pamphlets Health Facts books and posters The Draw the Lrne/Respect the Line program sets offer discounted pricing and range from I Grade 6 $218 99 to $389 99 Grade 7 $208 99 to $389 99 Grade 8 $157 99 to $291 99 For more information about Draw the Lfne/Respect the Lrne go to etr or it lf' Masters are included in teacher guides Copies will need to be budgeted for each student according to grades Grade 6 Activity sheets 18 Grade 7 Activity sheets 26 Grade 8 Activity sheets 26 A 2 page pre and post test is offered as a free download Copies will need to be budgeted for each student in each grade Estimated costs for two trainers to provide a 3 day training for 20 people is $22 265 Costs include training coordination materials design travel and supplemental training materials Every teacher will require a teacher guide for the training The 3 grade curriculum may be purchased for $21 per grade for grades 6 and 7 and $40 99 for rade 8 Technical support on adaptation and evaluation available and priced accordm to ro ram needs 14 Attachment ASSURANCES AND SIGNATURE FORM ln submitting this application to be included on the Mississippi Department of Education's Approved Supplemental Resource Services Provider List, I certify that: 1. The organization will comply with applicable federal, state, and local laws. 2. The organization is fiscally sound and will be able to complete services to Mississippi public schools. The organization will ensure that the instruction and content used are consistent with the instruction provided and content used by the local educational agency and are aligned with the Mississippi Curriculum Frameworks for Comprehensive Health. The undersigned hereby certifies that I am an individual authorized to act on behalf of the organization in submitting this application and assurances. certify that all of the information provided herein is true and accurate, to the best of my knowledge. understand that the discovery of deliberately misrepresented information contained herein may constitute grounds for denying the applicant's request for approval to be placed on the list of Approved Supplemental Resource Providers or for removal from the same list. Typed Name of Organization: ETR Associates Printed Name of Authorized Representative: David Kitchen .- 1 Signature of Authorized Representative "Lf" TH: Typed Title: Chief() eratin Officer Date Signed 20 2012 15