! FFeerrttiilliittyy NNuurrsseess ooff AAuussttrraallaassiiaa VVoolluummee 2200,, IIssssuuee 11

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Inside This Issue…

• Chairperson Report

• RTAC Report

• FSA Board Report • Around the States & Territories • Sponsorshp of FNA

• FNA Workshop Dec 2011

• Congratulations Donna Close

• A Good Deed

• FNA executive details

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Upcoming Events

Future Meetings:

. MMiidd yyeeaarr wwoorrkksshhoopp 1199tthh

MMaayy 22001122

• FFSSAA AAuucckkllaanndd OOcctt 22001122

• IICCAA 22001133

• FFSSAA SSyyddnneeyy 22001133

13 – 16 October 2013

• AASSPPIIRREE 22001144

4 – 6 April 2014

• FFSSAA CCaannbbeerrrraa 22001155 !

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CCHHAAIIRRPPEERRSSOONN RREEPPOORRTT Welcome to FNA’s first newsletter of 2012.

We held two very successful national FNA educational meetings in 2011, at the Gold Coast in May, and Melbourne in December. I thank the FNA representatives and their local team in providing dedicated and highly professional educational opportunities for FNA members and others working in the field of ART. We could not have run these meetings without the funding and physical help of our sponsors.

Platinum Sponsors in 2011 were MSD and Merck Serono who sponsored our major meetings as well as state run events. Our Bronze Sponsor was Orion and Bayer sponsorship allowed an FNA member from each state to attend a course of up to $500 and feedback information to their colleagues. Bayer and Orion also sponsored a breakfast speaker in Melbourne. Thank you to all our sponsors and Key Account Managers who have made valuable contributions to FNA throughout the year. This year I have contacted 14 companies to extend our sponsorship opportunities to a wider field. To date I am delighted to announce that we have continuing Platinum Sponsorship with Merck Serono and MSD. Ashmed has come on board as a

new Bronze Sponsor and we have continuing support from Orion. My friends, Rosemary Sayer and Terry Grose have become Friends of FNA as have the drug company, Ferring. I am continuing to talk to several other companies as to their level of commitment.

This is a wonderful start to FNA business in 2012 and will do a lot towards ongoing educational events for FNA members to access.

Plans are already going ahead for our two major meetings. The Midyear workshop in Canberra on May 19th is entitled “Fertility - from Woe to Go”. Judy McColl is heading her enthusiastic team and again we will have an early 0730 start with a guest speaker during breakfast. This proved to be quite popular in Melbourne and allows delegates to accrue 7CPD points.

Our New Zealand FNA representatives, Renata Stewart and Helen Mudgway are working towards an exciting program associated with FSA, to be held in Auckland on Saturday, October 28th. I acknowledge the hard work of the FNA committee in planning ongoing education throughout the year in each state and territory. This year I am working closely with Jan Mackenzie, FNA Chair Elect, so that the handover to her at our next AGM is smooth. Carmel Carrigan continues doing a great job as Treasurer and Judy McColl has taken on the job as Secretary for 2012 as well as maintaining the register of ART clinics.

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I thank Louise Younger as FNA’s representative to RTAC. Lou calmly and quietly does a brilliant job on behalf of nurses working in the field of ART to ensure we are kept abreast of any RTAC changes.

I congratulate Donna Close who now holds the role of Secretary of FSA as well as continuing as Nurse Representative to the board of FSA. Donna’s commitment to FSA and her articulate and organized style, ensure she is the right person to take on these extra duties. Together with Sandra Kennedy and Judith Applegarth, Donna continues to represent the nurse’s point of view at board level. I encourage all FNA members to renew their membership in 2012, to attend their local FNA meetings provided by our sponsors and state representatives and to apply for the Bayer/FNA scholarship which is open to all FNA members until March 31st.

The committee is currently in discussion regarding the cost to delegates of the midyear workshop. We hope to make it an event that is greatly reduced or free for FNA financial members. We look forward to seeing many of you in Canberra in May and in Auckland in October.

Sue Keogh.

FNA chairperson.

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Report to follow in the next newsletter.

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Report to follow in the next newsletter.

AARROOUUNNDD TTHHEE SSTTAATTEESS AANNDD TTEERRRRIITTOORRIIEESS WWEESSTTEERRNN AAUUSSTTRRAALLIIAA Last year finished with a Merck Serono sponsored event close to Christmas. Dr Ashley Makepeace spoke on ‘Thyroid Function in Fertility and Early Pregnancy’. It was a very informative talk which provided knowledge to take back and apply to our clinical work. It has otherwise been a quiet start to 2012. There will be a Bayer sponsored event at The University Club in mid-March. There are opportunities for ongoing education from external sources. A one day workshop is open to FNA members on Feb 11th. Linda Garland and Sue Keogh

VVIICCTTOORRIIAA Victoria saw a very busy end to 2011, successfully organising the FNA end of year meeting. We would like to take this opportunity to thank all who assisted with the preparation, and the inspirational speakers who gave up their time on a Sunday. Our thanks also go out to those of you who supported the meeting by attending, especially due to the early start time. It came at the end of a very long week for those attending FSA. For those who travelled from interstate for a Sunday meeting, we appreciate your attendance.

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VVIICCTTOORRIIAA ccoonntt..

We would like to particularly thank our platinum sponsors Merck Serono and MSD, Bayer for sponsoring our Breakfast speaker and Orion our Bronze sponsor.

We are currently finalising our local meetings for this year and hope to email the schedule to our members shortly. We are planning bi monthly journal club meetings as well as our dinner meetings for 2012.

Tamara Pearce and Rachael Varady !

SOUUTTHH AAUUSSTTRRAALLIIAA

Our end of year dinner meeting was well attended by most of S.A.’s fertility nurses. It was sponsored by MSD and Bayer and was presented by Professor Rob Norman entitled ‘An Update of PCOS’ – an intriguing condition which, as we all know can be very difficult to manage. This topic provoked a very interesting discussion.

Gill Homan, winner of the Bayer Scholarship attended a workshop titled ‘Avoid Death By Powerpoint’ – an interesting topic which Gill found to be very useful. She will talk about this at a future meeting – hopefully in February. We have a

few interesting speakers for this year lined up, but the final program still needs some fine tuning.

Robyn Trenouth and Maria Vitucci

TTAASSMMAANNIIAA !

Firstly a big thank you to Julie Findlay for doing a wonderful job for the past two years as Tasmania’s FNA rep.

2011 was a busy year for TasIVF. Dorina from MSD visited us a number of times, and presented some very interesting topics including education on Elonva, and a review of a clinical paper which looked at why couples drop out of IVF treatment. Two of our nurses and two scientists attended the FSA end of year workshop, and we’re all looking forward to hearing from them what they learnt. Our Donor Coordinator found many of the topics very relevant. One of our nurses attended a seminar on anesthetics and complementary medicine at the end of last year, which was very interesting and certainly relevant to fertility treatment.

2012 is already off to a busy start. We were lucky to have Dr David Greening from SydneyIVF work with us for two weeks in January, whilst our clinical director Dr Bill Watkins was away on

holiday. Our Nurse Unit Manager Fiona Reeve is no longer working at TasIVF, so we’re currently seeking a new manager. We’re looking forward to re-commencing our regular weekly in-services in February, which cover a range of topics for nurses and scientists. Nina from Bayer has an education session planned for the end of February.

QQUUEEEENNSSLLAANNDD Although the start of 2011 was not that great for our state in terms of natural disasters we wound up the year on a high with a very well supported dinner meeting. We had an amazing total of 51 attendees for this final meeting for the year which was held at Victoria Park Function Venue. A number of nurse’s from both Toowoomba and the Gold Coast went to great effort to make the educational evening. Dr Ben Kroon (QFG) provided a very informative presentation entitled: “Luteal Phase Support What the evidence suggests…” This was a very interesting topic which stimulated lively discussion amongst the group.

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QQUUEEEENNSSLLAANNDD CCoonntt.. Ms Misty Hatfield (City Fertility Centre) presented “Vitrification a few years on…”which shed light on the different methods of cryopreservation and reviewed success rates a few years on. We certainly enjoyed the topics presented and thank both Ben and Misty for giving up their valuable time at what is usually an extremely busy time of the year.

We were also inspired with the assistance of our local KAMs to facilitate a multi prize raffle on the night to provide some support for our friend and colleague Leesa Saunders. Leesa’s daughter Chloe aged 10 was diagnosed with a brain tumour earlier in the year and Leesa had taken leave to care for her throughout her illness. Sadly Chloe passed away peacefully on Christmas Eve.

We appreciate the continued support we receive in order to provide these local educational events, Merck Serono and MSD have especially been fabulous in continuing to support our local meetings. Special thanks must be extended to our wonderful Key Account Managers Wil, Cath and Kirsty and the Bayer team who have pledged to continue their support in 2012.

Our first official educational event for 2012 will be a journal club that will be held at Assisted Conception Australia, Greenslopes in the coming weeks.

Hoping for a successful New Year for all fertility nurses and may nature be kind to us all.

Carmel Carrigan and Lou Hayes

NNEEWW SSOOUUTTHH WWAALLEESS NSW kicked off the year with its first meeting on February 1st at IVFA Bondi Junction. Delia McCarthy, acupuncturist/herbalist and manager of the Acupuncture IVF Support Clinics in Sydney, explained the role of acupuncture in ART and pregnancy. Hopefully inspiring nurses to encourage their patients to embrace its benefits. Sandy Emerson, Clinical Midwifery Consultant at the Fetal Medicine Unit, Royal Hospital for Women, shocked attendees with her case studies of multiple pregnancies and the complications that can arise. Interestingly, a lot of these came from IUI or OI cycles and with such risky complications should make us carefully consider proceeding with cycles which carry any risk of a twin/triplet pregnancy. A ‘Save the Date’ flyer went out at the beginning of the year. Educational meetings in Sydney are scheduled to take place on Tues 5th June, the annual Bayer Dinner July/August TBA and Wed 5th December. Not forgetting additional CPD points can be obtained at the Mid Year Workshop in Canberra on the 19th of May and the FNA Meeting at FSA on October 28th in Auckland. NSW

FNA members are encouraged to attend the Mid Year Workshop as 7 CPD points can be achieved in one day of education and although interstate, a weekend in Canberra is a feasible trip. A special thanks must go out to our reps who really do make our educational meetings so successful: Sally and Nez from Merck Serono, Amanda and Mathew from MSD, both FNA platinum sponsors, along with Elias, Gopi and Fareha from Orion, FNA bronze sponsors. We look forward to seeing many of you at the Mid Year Workshop. Lauren Metliss and Jan Mackenzie

Note from the Editor If any FNA member has anything

they want included in the newsletter, whether it be member achievements, articles, photos etc,

please forward it to lmetliss@ivf.com.au

LLaauurreenn

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AAUUSSTTRRAALLIIAANN CCAAPPIITTAALL TTEERRRRIITTOORRYY We have a busy few months ahead organizing the mid year “Fertility – From Woe to Go” workshop planned for Saturday 19th May, 2012.

A motivated committee is putting together a very interesting program. With our heads together some great people have been unearthed in Canberra!

We hope to see a great roll up. Accommodation has been tentatively held and the conference will be held in the airy convention centre at Manuka Oval. Please mark it in your diary.

It will be a great opportunity for FNA members to learn and network. 7 CPD points will be earned on the day. KKeeeepp aann eeyyee oouutt ffoorr eemmaaii llss ccoommiinngg tthhrroouugghh rreeggaarrddiinngg rreeggiissttrraattiioonn..

On a local note our local FNA group will be attending a dinner supported by Bayer on February 29th . Dr Nicole Sides will present as will Vaunlea Morrison, last years Bayer scholarship winner.

Please do not hesitate to make contact if you would like further information regarding the workshop: jmccoll@isisfertility.com.au

Judy McColl

NNEEWW ZZEEAALLAANNDD !

No report this newsletter. Renata Stewart and Helen Mudgway

A message to all clinics in Australia and New Zealand

FFNNAA UUnniitt RReeggiisstteerr

Would anyone like to update their details from the clinic register? Please check your details by going online to the FNA website. Scroll down to the Unit Register and find your clinic.

Please send you updates to Judy McColl at: jmccoll@isisfertility.com.au.

Previous updates have been received. These will be updated as soon as possible. Unfortunately it is not an easy process but it is great to now be on the FSA Website! A big thank you to Donna and Kim

Judy McColl

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SSPPOONNSSOORRSSHHIIPP OOFF FFNNAA Each year sponsorship is sought to help fund FNA to continue to provide educational opportunities to ART nurses. As stated in the Policy and Procedures manual, sponsorship of FNA offers opportunities to: • Collaboratively assist in the

organisation of workshops and educational meetings.

• Provide financial support for nurses to attend conferences. For example, the American Society of Reproductive Medicine and the Fertility Society of Australia.

• Support nursing based research.

• Support nurses presenting research papers at conferences.

• Have a strong presence in FNA newsletters and contribute to the FSA newsletter as deemed appropriate by the committee.

• Network between ART nurses in Australia, New Zealand and overseas locations.

• Financial support to send one nurse from the Executive Committee to New Zealand to the New Zealand FNA AGM Workshop and to send one New Zealand Executive Committee nurse to the FSA related FNA AGM meeting. This encourages a good working relationship with FNA members in both countries.

• Work with FNA on new learning projects and initiatives such as an e-learning program that would reach all FNA members to enable them to fulfill educational requirements for the new National Nurses Registration, which was introduced in 2010.

• Provide airfares to allow Executive Members to travel to

FNA associated meetings twice a year.

• Help support two telephone link ups for the Executive Members twice per year

There are 5 levels of sponsorship: PLATINUM SPONSOR Premium sponsor of the FNA GOLD SPONSOR Major sponsor of mid-year workshop or FNA workshop at the annual FSA Meeting SILVER SPONSOR Opportunity for 15 min presentation at local meeting where appropriate at FNA midyear and FSA workshops on a topic relevant to FNA membership BRONZE SPONSOR Acknowledgement of support in each edition of FNA newsletter FRIEND OF FNA Acknowledgement of support in FNA newsletter

BBRROONNZZEE SSPPOONNSSOORR

ORION ASHMED

FFRRIIEENNDD ooff FFNNAA FERRING Rosemary Sayer & Terry Grose

PPLLAATTIINNUUMM SSPPOONNSSOORRSS

MSD MERCK SERONO

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FFNNAA WWOORRKKSSHHOOPP MMeellbboouurrnnee,, DDeecc 22001111 !

An extremely successful FNA workshop, themed ‘Modern Familes’, was held on Sunday 4th December In Melbourne. Well done and thank you to the Victorian FNA Reps, Tamara Pearce and Rachael Varady, along with their organising committee for the time and effort in putting together such an extensive day.

An example of speakers on the day included:

1. Prof David Amor: HEALTH OUTCOMES IN BABIES, CHILDREN AND YOUNG ADULTS CONCEIVED USING ART. Early follow up studies suggest the frequency of birth defects in babies conceived through ART is 2-3% - comparable to naturally conceived. However there is evidence of an increased risk of rare imprinting disorders in babies conceived using ART. Imprinting disorders include Prader-Willi Syndrome, Angelman Syndrome, Transient Neonatal Diabetes, Beckwith-Wiedermann Syndrome. Awaiting results and publication of the NHMRC IVF Young Adults Study.

2. Louise Johnson: PUBLIC EDUCATION: ART, CHILDREN AND THE PREVENTION OF INFERTILITY. VARTA (Victorian Assisted Reproductive Treatment Authority) registers ART clinics, promotes public education,

community consultation and research into causes and prevention of infertility. It monitors programs and activities and approves the import/export of donor gamete/embryos.

3. Bernadette Wooten: ATLANTA CENTER FOR REPRODUCTIVE MEDICINE Patients <43 can use their own eggs, patients >43 MUST use donor oocytes. Allowed to cycle up until their 51st birthday and a couples combined age should be less than 100 years. There is no national healthcare and most insurance companies only cover up to the diagnosis of infertility, with treatment being an out of pocket cost for patients.

IVF cycle fees = $12550 + medications ranging from $2500-$5500. Donor egg cycles cost approx $27000. FET’s cost $4000 + medications ranging from $400-$900. A ‘refund program’ is available - 70% of costs refunded if “no take home baby’ after 3 fresh and 3 frozen cycles. Upfront cost if <35 years = $27500, if 35-37 years $29500, if >37 years, refund program unavailable.

If <37 years 2 embryos were typically transferred, if >38 more embryos were transferred, depending on quality.

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CCOONNGGRRAATTUULLAATTIIOONNSS DDOONNNNAA CCLLOOSSEE!!

Donna Close, FNA Representative to the FSA, won ‘BEST PRESENTATION BY A NURSE’ at the recent 14th World Congress on Human Reproduction, in Melbourne in December 2011. Congratulations on a outstanding achievement Donna! An abstract is detailed below.

RReeggiioonnaall VVaarriiaattiioonnss iinn tthhee DDeemmooggrraapphhiiccss ooff PPaattiieennttss SSeeeekkiinngg IInnffeerrttii ll iittyy TTrreeaattmmeenntt

DDOONNNNAA CCLLOOSSEE, LEITA FEIN, ANGELA HERRON, LENA ASTBURY, MARGARET SCHILLING, KEITH HARRISON (Queensland Fertility Group, various sites across Qld)

Aim: This study seeks to understand and interpret similarities and variances in demographic data between patients presenting for infertility diagnosis and treatment in Brisbane and regional clinics on the Gold Coast, Toowoomba, Mackay, Townsville and Cairns. This knowledge will enable better deployment of resources for patients.

Method: The study compares new patients demographics in each region over a recent five year period. 1200 new patients presenting between 2005-2009 were randomly selected, 200 from each clinic’s database. De-identified information was collected from the initial nurse interview. The data was compared,

contrasted and analysed under several headings, including patient age, age at presentation, the nature of their social relationship, duration of infertility and aetiology.

Results: Regional differences emerged in several areas. The mean age at presentation was 33.5 years. Cairns and Gold Coast patients presented 7 months later at 34.2 years. 5% of all patients presenting for treatment have been trying for 2 years or more. 12% of women presenting for treatment in the >39 age group had been trying for >3 years; leading us to question the effectiveness of recent educational initiatives promoting the benefit of seeking treatment earlier. Interesting trends emerged in the analysis of domestic relationships. Same sex couples seeking treatment remained fairly even across all regions, however single women only presented in the south east corner, on the Gold Coast and in Brisbane.

Conclusion: Resources for patient education, consents and information can be tailored to the demographics of each particular region to optimize the patient outcome in terms of success, retention and emotional well being.

Abstract taken from the ‘Book of Abstracts’ - 14th World Congress on Human Reproduction.

Additionally, Donna concluded in her presentation:

* There is a higher incidence of male factor infertility in Brisbane,

Townsville and Gold Coast with resource implications on ICSI equipment and urological support.

* When planning for capital expenditure, scientific staff and managers should review their individual percentage of male factor infertility as well as cycle number thresholds to ensure adequate access to ICSI apparatus.

* Single women desiring donor semen are a significant part of our practice, particularly in the south-east corner.

* Social infertility patients are most likely to be well educated and may require greater sophistication in information delivery.

* Same-sex couples desiring donor semen are encountered in all locations, constituting a significant 8% of all patients presenting to Brisbane infertility specialists.

* If their needs are to be met we need strategies to source more donor semen.

* We need to develop educational material and consent forms that are compatible with the social circumstances of these two patient groups.

* Unskilled workers comprise up to 30% of our patients while blue-collar workers form up to 50% of our patient groups, particularly in rural locations.

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* We need to ensure that the oral and written information that we provide to them is set at a level that they can clearly understand.

* In the south-east corner around 10% of the patients are not employed, predominantly because they already have a child/children and they are suffering secondary infertility. Good information on secondary infertility needs to be available to them.

* Tubal infertility is more common in the regions than Brisbane and possibly the “safe-sex” messages are failing outside the capital.

* Women seeking oocyte donation present most commonly in the south east corner of the state. This study highlights the need to resource this option more actively in the regions.

* Women seeking fertility preservation are seen almost exclusively in Brisbane, possibly as it is a central provider of oncology treatments for the state. We should however make regional oncologists and surgeons more aware of the fertility preservation options.

* Exercises such as this should stimulate discussion and encourage us to improve the manner in which we provide care for our patients.

* Data can inform how we deliver our patient education, how we resource our clinics, what services to plan for in the future.

* Wider implications could include information for training programs for rural specialists and public health initiatives for the wider community.

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AA GGOOOODD DDEEEEDD!!

Here is a photo of Francesca, a lovely Doctor who works at the Bairo Pita Clinic in Dili, Timor.

A little while ago Monash IVF at Sunnybank upgraded their old ultrasound machine. Some time later, I became aware that a Brisbane based Fertility Specialist from ACA, Dr Stephen Cattanach, was planning to travel to Timor to do some volunteer medical work. One thing led to another and with Monash’s approval, we arranged for Steve to pick up the machine, the probes and an old printer to take with him on his trip.

Steve told us that the staff at the antenatal clinic had no ultrasound facilities for routine antenatal care and basically were never really sure about their patient’s gestation dates. They were really thrilled to have access to this modern technology.

To think that we thought it was an old clunker! It is humbling to realise how fortunate we are to have access to new updated equipment so readily. We are also grateful to Steve for his efforts and his good work in Timor.

Lou Younger, FNA member for RTAC

SSaavvee tthhee ddaattee::

FFNNAA MMIIDD YYEEAARR WWOORRKKSSHHOOPP 22001122

““FFEERRTTIILLIITTYY –– FFRROOMM WWOOEE TTOO GGOO””

Where: Canberra ACT

When: Saturday May 19, 2012

Venue: Manuka Oval Convention Centre

Stay in the Parliamentary Triangle at one of the hotels close to the venue

Workshop will commence at 7.30am with breakfast and is open to all FNA members

Earn 7 CPD points in one day! Fly in on Friday evening and get together with your colleagues

With an action packed day you could be on your way home by 4.30pm or stay over and see the sights of Canberra

For more information contact:

ACT FNA Representative Judy McColl

jmccoll@isisfertility.com.au or 02 61759000

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22001111 FFNNAA CCoommmmiitttteeee

Sue Keogh Chairperson and WA Representative.

susan.r.keogh@gmail.com

Jan MacKenzie Chair Elect and NSW Representative

jmackenzie@nextgenfertility.com.au

Judy McColl Secretary and ACT Representative njmccoll@bigpond.com

Carmel Carrigan Treasurer and QLD Representative carmel.carrigan@qfg.com.au

Donna Close FNA Representative to the FSA Board of Directors

donna.close@qfg.com.au

Home: donnaclose@me.com

Louise Younger FNA member of RTAC louise.younger@qfg.com.au

Home: louiseyounger@gmail.com

Lauren Metliss Newsletter Editor & NSW Representative

lmetliss@ivf.com.au

Linda Garland WA Representative. linda@fertilitywa.com.au

Louise Hayes QLD Representative. louise@cityfertility.com.au

Tamara Pearce Victoria Representative. tamarapearce@cfcmelb.com.au

Rachael Varady Victoria Representative. rachael.varady@mivf.com.au

Renata Stewart NZ Representative. rstewart@repromed.co.nz

Robyn Trenouth SA Representative. robyn.t@flindersivf.com.au

Tasmania Representative.

Helen Mudgway NZ Representative hmudgway@fertilityassociates.co.nz

Maria Vitucci SA Representative mvitucci@repromed.com.au

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22001122 BBaayyeerr//FFNNAA CCoommbbiinneedd SSppoonnssoorrsshhiipp OOppppoorrttuunniittyy AApppplliiccaattiioonn FFoorrmm

NNaammee:: …………………………………………………………………………......................................................................................

AAddddrreessss:: ....………………………………………………………………………………....................................................................

SSttaattee:: …………………………………………………………………………………………………………………………………………....

FFNNAA AAccccrreeddiittaattiioonn NNoo..::…………………………………………………………………………………………..........

CCoouurrssee//CCoonnffeerreennccee yyoouu aarree aappppllyyiinngg ffoorr:: ..................................................................

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SSttaattee rreeaassoonnss yyoouu wwiisshh ttoo aatttteenndd:: ……………………………………………………………………..

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WWhhaatt ddoo yyoouu sseeee aass tthhee kkeeyy lleeaarrnniinngg oouuttccoommeess ffoorr tthhiiss CCoouurrssee//CCoonnffeerreennccee??**......................................................................................................................................

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IIff ssuucccceessssffuull,, yyoouu wwiill ll bbee eexxppeecctteedd ttoo pprreesseenntt aatt aa BBaayyeerr ssppoonnssoorreedd

FFNNAA mmeeeettiinngg,, &&//oorr ccll iinniicc iinn--sseerrvviiccee aass wweellll aass pprroovviiddiinngg aa sshhoorrtt

ssuummmmaarryy ttoo tthhee FFNNAA nneewwsslleetttteerr**..

II aaggrreeee ttoo tthhee aabboovvee ccoonnddiittiioonnss::

SSiiggnneedd:: ……………………………………………………………………………………………………………………………………....

DDaattee:: …………………………………………………………………………………………………………………………………………....

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