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WALDEN, Colo where to buy generic zithromax. €” The building that once housed the last drugstore in this town of fewer than 600 is now a barbecue restaurant, where pit boss Larry Holtman dishes out smoked brisket and pulled pork across the same counter where pharmacists dispensed vital medications more than 30 years ago. It’s an hourlong drive over treacherous mountain passes where to buy generic zithromax to Laramie, Wyoming, or Granby or Steamboat Springs, Colorado — and the nearest pharmacies. The routes out of the valley in which Walden lies are regularly closed by heavy winter snows, keeping residents in and medications out.

Walden has suffered the fate of many small towns across the United States, as the economics of the pharmacy business have made it difficult for where to buy generic zithromax community drugstores to survive. With large pharmacy chains buying up independent drugstores and increasingly controlling the supply chain, towns such as Walden have too few residents to attract a chain drugstore and no great appeal for pharmacists willing to strike out on their own. With no local access to prescription drugs, the town of mainly cattle ranchers and hay farmers has crowdsourced a delivery system, taking advantage of anyone’s trip to those bigger cities to pick up medications for the rest of the town. €œReally, it’s a network of community and people reaching out and knowing that others have needs,” said Tina Maddux, who runs a nonprofit that provides food and other assistance in where to buy generic zithromax Walden.

€œWe’re a community that pulls together for the wellness of everyone.” The system is just one of the creative ways that rural communities deal with a lack of health care. In Walden, the senior center runs a regular shuttle to the bigger locales so older residents don’t have to drive where to buy generic zithromax to pick up groceries, visit doctors or refill their meds. In October, a pharmacy in Steamboat Springs began delivering medications to Walden once a week. Mail-order pharmacies can help with medications for chronic conditions, but not for acute needs.

Yet these where to buy generic zithromax solutions can’t replace a bricks-and-mortar pharmacy, as pharmacists do much more than count pills. They can give flu or buy antibiotics shots and, in some states, such as Colorado, even prescribe contraceptives. Some run where to buy generic zithromax diabetes management or smoking cessation programs. Medications can be complicated, and without a live person to talk to, patients can struggle to take them correctly.

In Walden, Colorado — a town of fewer than 600 residents that no longer has a drugstore — residents are crowdsourcing ways of getting prescription medicines delivered to those who can’t travel the long distances to the closest big community with a pharmacist.(Kyle Spradley / for KHN) All Smoked Up BBQ in downtown Walden used to be a pharmacy — the last drugstore in the town. Smoked brisket and pulled pork now move where to buy generic zithromax across the same counter where pharmacists dispensed vital medications more than 30 years ago. (Kyle Spradley / for KHN) In Walden, locals are one snowstorm, one mishap, from being cut off from their meds. That uncertainty leaves Whitney Milek where to buy generic zithromax with constant anxiety.

Her younger son, 8-year-old Wade, relies on medications to control his seizures. She usually picks up his medicines in Laramie, where the family does its big grocery runs. But when she needs to refill in between trips, she where to buy generic zithromax turns to her neighbors for help. The informal system runs primarily through a Facebook group created in 2013 as a sort of online garage sale.

For years, people have been posting to ask if anybody is headed toward a where to buy generic zithromax pharmacy and can bring back a prescription. Neighbors deliver to neighbors, even during the zithromax, and no money is exchanged. €œThere are times when nobody is going and you end up having to have them mailed, which is a whole other thing, especially with seizure meds,” Milek said. €œSome are controlled substances and they can’t mail them.” Two where to buy generic zithromax winters ago, Milek called in one of her son’s prescriptions to a Steamboat Springs pharmacy.

But when she arrived, the medication was out of stock. With road conditions rapidly worsening, she asked if the pharmacy would where to buy generic zithromax mail the medication but was told she lived too close for mail delivery. She turned to a pharmacy in Laramie, which eventually agreed to mail it to her — but also didn’t have it in stock. €œSo, he ended up going five where to buy generic zithromax days without,” Milek said.

€œIt’s not a big deal if you miss a dose here or there. But when you miss that many over a period of time, your tolerance level goes down.” That medication must be carefully managed to build up gradually in Wade’s blood to avoid a severe allergic reaction. It took three weeks to scale up to his daily dose when he started taking where to buy generic zithromax the drug two years ago. €œWhen he went five days without it, he had to basically start all over again.

It was over Christmas where to buy generic zithromax break, so he wasn’t in school. I brought him to work with me because I didn’t feel comfortable leaving him with anybody else,” said Milek, a bookkeeper. €œI didn’t know what was going to happen.” Whitney Milek’s younger son, Wade, relies on medications to control his seizures. The family, photographed in March 2020 before the buy antibiotics zithromax took hold, lives in Walden, Colorado, an hour’s where to buy generic zithromax drive over treacherous mountain passes to Laramie, Wyoming.

That’s where they get groceries — and often pick up Wade’s prescriptions. But sometimes they need refills before they can make those trips and rely on help from neighbors.(Kyle Spradley / for KHN) Wade was where to buy generic zithromax fortunate to avoid complications that time. But having a local pharmacy mail medications comes with added costs — $26, in their case, for a prescription last month — an extra tax on those who cannot get to a pharmacy. Mail-order pharmacies typically don’t charge for shipping yet can run into snags, too.

Last year, some of Wade’s mailed medications got stuck in a Denver where to buy generic zithromax processing facility for three weeks. The Mileks had to pay $1,600 out-of-pocket to get replacements. Walden has where to buy generic zithromax no hospital, only a small clinic where Dr. Lynnette Telck and a nurse practitioner care for residents.

The clinic stocks some basic medications to handle routine acute needs — antibiotics for strep throat, inhalers for asthma — and they can mix up liquid suspensions for those who can’t swallow pills. €œIt’s a small town, so where to buy generic zithromax we all wear many hats,” Telck said. Studies show that, without a drugstore nearby, patients aren’t as likely to keep up with their medications and their chronic conditions can worsen. Without readily available medications, Telck said, patients can where to buy generic zithromax end up taking an ambulance to an emergency room.

€œIt’s just so darn expensive to the system,” she said. Walden touts itself as the moose-viewing capital of Colorado and is a recreation mecca for hunting, fishing and snowmobiling. But Telck said it could be hard to attract a pharmacist where to buy generic zithromax because the town lacks amenities like movie theaters and shopping malls. €œIt’s pristine and wonderful in its own quirky way and we love it,” she said.

€œBut not a lot where to buy generic zithromax of people want to come to rural areas. The wages aren’t as high as in the big cities.” Middle Park Health, the Granby-based hospital system that operates the Walden clinic, had looked at putting a more complete pharmacy in the clinic but couldn’t find a technician to staff it. €œThe days of that being a profitable, desirable business? where to buy generic zithromax. It’s a lot tougher than it was a decade or two ago,” said Gina Moore, an associate dean at the University of Colorado’s School of Pharmacy.

€œYou come out of eight years of college — four years of undergraduate and four years of pharmacy school — with pretty significant student loan debt. It’s very hard to go to a rural community where you don’t make where to buy generic zithromax any money.” In towns without an ER or a clinic open late, pharmacists often become the health provider of last resort. They tell patients whether they need to make the long trek to a hospital late at night or can wait until morning. €œA patient will where to buy generic zithromax often come to the pharmacy as the first point of access for health care,” Moore said.

€œOur pharmacists are taught to understand and to be able to advise people on what can be self-treated with over-the-counter medications versus when you need to see a higher-level provider or an urgent care.” Researchers from the Rural Policy Research Institute at the University of Iowa have documented how the deck is increasingly stacked against community pharmacies. €œIt’s just not a really attractive business model anymore,” said Keith Mueller, the institute’s director. In 2013, they found that new Medicare Part D drug plans resulted in low and late where to buy generic zithromax reimbursements, replacing direct out-of-pocket payments from customers. That left many pharmacies unable to turn a profit.

By 2018, surveys showed pharmacies were struggling more with where to buy generic zithromax the narrowing margin between what they paid for the drugs and what they were being reimbursed by health plans. Towns of more than 10,000 people are often served by at least a Walmart or a supermarket pharmacy, Mueller said. €œBut you get out into smaller communities, the predominant modality had been the corner drugstore,” he said. €œWe’re not seeing that replacement of the closed independents by a CVS, Rite Aid or Walgreens.” The Mileks have talked about whether they should move near her family in where to buy generic zithromax Wyoming to be closer to a hospital and pharmacy.

€œWhen you can’t get to a pharmacy, it’s scary, because things can happen so fast,” Milek said. €œPeople just where to buy generic zithromax have no concept of what it’s like out here.” The Milek family, photographed in March 2020 before the buy antibiotics zithromax took hold, has talked about whether they need to leave rural Walden, Colorado, to move near family in Wyoming to be closer to a hospital and pharmacy. Their younger son, Wade, relies on medications to control his seizures and Walden does not have a pharmacy, making it challenging to get his medications.(Kyle Spradley / for KHN) Markian Hawryluk. MarkianH@kff.org, @MarkianHawryluk Related Topics Contact Us Submit a Story TipToday, thanks to the American Rescue Plan, the US Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA) awarded $125 million to support 14 nonprofit private or public organizations to reach underserved communities in all 50 states plus the District of Columbia, Puerto Rico, Guam and the Freely Associated States to develop and support a community-based workforce that will engage in locally tailored efforts to build treatment confidence and bolster buy antibiotics vaccinations in underserved communities.These awards reflect the first of two funding opportunities announced by President Biden last month for community-based efforts to hire and mobilize community outreach workers, community health workers, social support specialists, and others to increase treatment access for the hardest-hit and highest-risk communities through high-touch, on-the-ground outreach to educate and assist individuals in getting the information they need about vaccinations.

€œFor many of us, it’s best to hear from a friend or community leader when deciding whether to make a big decision, like taking the buy antibiotics where to buy generic zithromax treatment. To reach President Biden’s goal of 70 percent of the U.S. Adult population having one treatment shot by July 4th, we are doing everything we can to reach marginalized communities with lower vaccination where to buy generic zithromax rates,” said HHS Secretary Xavier Becerra. “These awards will enable trusted, community-based organizations to use strategies tailored to the populations and areas they know best to address persistent racial, ethnic, and socioeconomic health inequities.” The workers supported with this funding will answer individual questions, help make treatment appointments, and assist with transportation and other needs.

Award recipients will collaborate with regional and local partners to ensure a broad geographic reach with the goal of getting as many people vaccinated as possible. €œTrusted messengers play an essential role in sharing information about buy antibiotics treatments, answering questions, and ultimately convincing people where to buy generic zithromax to get vaccinated,” said Acting HRSA Administrator Diana Espinosa. €œThis funding will support national, regional, and local organizations that will work directly with hard-hit, underserved, and high-risk communities to help bolster buy antibiotics vaccination rates.” For a list of awards recipients, see www.hrsa.gov/antibiotics/community-based-workforce. HRSA has also released a second notice of funding opportunity targeting smaller community-based organizations, with awards expected to be released in July 2021 where to buy generic zithromax.

Contact CBOtreatmentOutreach@hrsa.gov with any questions. Learn more about how HRSA is addressing buy antibiotics and health equity..

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Diagnostic errors in hospital medicine Zithromax cost have mostly what do i need to buy zithromax remained in uncharted waters.1 This is partly because several factors make measurement of diagnostic errors challenging. Patients are often admitted to hospitals with a tentative diagnosis and need additional diagnostic investigations to determine next what do i need to buy zithromax steps. This evolving nature of a diagnosis makes it hard to determine when the correct diagnosis could have been established and if a more specific diagnosis was needed to start the right treatment.2 Hospitalised patients also may have diagnoses that are atypical or rare and pose dilemmas for treating clinicians. As a result, what do i need to buy zithromax delays in diagnosis may not necessarily be related to a diagnostic error. Furthermore, what types of diagnostic errors occur in the hospital and their prevalence depends on how one what do i need to buy zithromax defines them.

Different approaches to define them have included counting missed, wrong or delayed diagnoses regardless of whether there was a process error;3 counting them only when there was a clear ‘missed opportunity’ – ie, something different could have been done to make the correct or timely diagnosis;4 or diagnostic adverse events (ie, diagnostic errors resulting in harm);5 all leading to views of the problem through different lenses.Two articles in this issue of the journal provide new insights into the epidemiology of diagnostic errors in hospitalised patients.6 7 Gunderson and colleagues conducted a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients.6 Raffel and colleagues studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors.7 Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals. We discuss the significance of the results for hospital medicine and implications for emerging research and practice improvement efforts.Finding diagnostic errors in hospitalsGunderson and colleagues performed a systematic what do i need to buy zithromax review and meta-analysis to inform a new estimate for the prevalence of diagnostic adverse events among hospitalised patients, a rate of 0.7%.6 Their review shows how diagnostic error is a global problem, with studies from countries across five continents. The prevalence however is lower than what might be expected looking at previous research, mostly in outpatient care, and based on expert estimates.8–11 The prevalence of diagnostic error in hospital care may be lower because outpatient care, especially primary care, has the challenging task of identifying patients with a serious disease from a large sample of patients who present with common symptoms and mostly benign non-urgent diseases. A higher state of attention in the hospital and higher prior probability of a patient having a more serious disease may also reduce the likelihood of something being missed (ie, the prevalence effect).12 13 Furthermore, the hospital setting offers more diagnostic evaluation possibilities (consultations, imaging, laboratory) and more members of the diagnostic team to alert a clinician on the wrong diagnostic track.The heterogeneity of the studies in the review and meta-analysis and a broad scope may also explain the lower prevalence rate.6 14 The included studies did not have an exclusive focus on detecting diagnostic errors but rather aimed to identify all types of adverse events, including medication and surgical adverse events,5 15 which are relatively easier to measure what do i need to buy zithromax. Consequently, the data collection instruments were likely not sufficiently sensitive to pick up diagnostic adverse events, resulting in an what do i need to buy zithromax underestimation.

Some diagnostic adverse events may also be classified as ‘other’ types. For instance delayed diagnosis of a wound leakage after surgery is often considered a surgical complication and not categorised what do i need to buy zithromax as a delay in diagnosis.16 Studies in the review also detected adverse events (ie, errors that resulted in harm)6 which is a subgroup of diagnostic errors, because not every diagnostic error results in harm.17 Lastly, while the random selection of patients is a strength for determining prevalence of medical error, not all admissions involve making a diagnosis—patients are often hospitalised for treatment and procedures. As the literature in the area becomes more robust, future reviews may be able to provide an updated estimate. For now, Gunderson and colleagues estimate 250,000 diagnostic adverse events occur annually in the USA, which should be alarming enough to warrant attention and intervention.While the study by Raffel and colleagues is not a true prevalence study (it only evaluated 7-day readmissions), it uses dedicated tools to identify diagnostic error what do i need to buy zithromax in hospitals, a crucial next step. By examining a subset of hospital admissions at what do i need to buy zithromax greater risk of diagnosis-related problems (ie, readmissions within 7 days after hospital discharge) and by using tools dedicated to identifying diagnostic error, the investigators were able to describe error types and contributing factors.

The advantage of studying such a high-risk sample is that diagnostic errors can be found more efficiently, that is, the positive predictive value is higher than if you review all consecutive patients. This could identify a higher number of cases to identify contributing factors what do i need to buy zithromax. While the positive predictive value they achieved through this method was still rather low, methods to selectively identify diagnostic errors are valuable in measurement efforts. Future studies what do i need to buy zithromax could build on this work to develop sampling methods with higher predictive values that can be used by others for research and practice improvement.Diseases at risk for diagnostic error in the hospital settingTypes of conditions involved in diagnostic error in both studies reflect a broad range of diseases commonly identified in previous studies, such as malignancies, pulmonary embolism, aortic aneurysm and s.5 8 18 A recent malpractice claims-based study has led some to suggest that initial diagnostic error reduction efforts, including allocation of funding for research and quality measurement/improvement, should focus on three broad types of disease categories, the so-called ‘Big Three’, namely cancer, s and cardiovascular diseases, because they are highly prevalent and result in significant harm.11 19 20 These three disease categories cover a large portion of diagnoses made in medicine. Indeed, data beyond claims also suggest that diagnostic errors in each what do i need to buy zithromax of these categories are common.5 18 However, diagnostic errors span a large range of other diseases as shown in both studies, which is similar to what prior studies have found.

For instance, in one primary care study, 68 unique diagnoses were missed with the most common condition accounting for only 6.7% of errors.21Contributing factors in hospital medicineRaffel and colleagues applied established tools (ie, SAFER Dx22 and DEER23) to identify contributing factors. They found that most of these what do i need to buy zithromax involved failures in clinical assessment and/or testing. Contributing factors in what do i need to buy zithromax these two domains occurred in more than 90% of diagnostic errors, a high proportion consistent with previous work.8 17 18 Furthermore, these main contributing factors are common across diagnostic errors regardless of the diseases involved. For instance, similar process breakdowns emerge across different types of missed cancer diagnoses.24–26Finding ‘Forests’ not just the ‘Big Trees’ to enable scientific progressSo should initial scientific efforts just target disease categories?. And if so, should they address just the ‘Big what do i need to buy zithromax Three’?.

Data from prior studies across different settings, including those from Gunderson and Raffel and colleagues, find large diversity in misdiagnosed diseases.5–7 18 21 27 This suggests that an exclusive focus on the ‘Big Three’ would neglect a substantial proportion of other common and harmful diagnostic errors.27 Furthermore, research on contributing factors of diagnostic errors reveals a number of common system and process factors that would require robust disease-agnostic approaches. If funding and advocacy for diagnostic safety becomes mostly disease oriented, it will pull resources away from broader ‘disease-agnostic’ research and quality improvement efforts needed to understand and address these underlying system and process factors.28 Biomedical research is already quite disease focused and supported by many disease-specific institutes and this now needs to be balanced what do i need to buy zithromax by work that catalyses much-needed foundational and cross-cutting healthcare delivery system improvements.We would thus recommend a balanced strategy that carefully combines disease-specific and disease-agnostic approaches to help address common contributing factors, system issues and process breakdowns for diagnostic error that cut across these many unique diseases. For example, if new quality measures to quantify what do i need to buy zithromax delays in colorectal cancer diagnosis and missed diagnosis of sepsis are developed, we would also need ‘disease-agnostic’ studies that evaluate the implementation and effectiveness of such measures. This includes how they fit within current measurement programmes, what their measurement burden is and what the unintended consequences may be. A combined approach would create more synergistic and collaborative understanding in addition to enabling application of common frameworks and approaches to multiple conditions, rather than ‘reinventing the wheel’ what do i need to buy zithromax for each disease or disease category.

This type of approach may have a larger population-based impact and help us see the entire ‘forest’ to reduce diagnostic error.Implications for practice improvementA crucial first step for improving diagnosis in hospitals is to create programmes to identify and analyse diagnostic errors.29 Most hospitals have systems and programmes in place to report and analyse safety issues such as falls, surgical complications and medication errors, but they do not capture diagnostic errors. With increased what do i need to buy zithromax recognition of risks for diagnostic error, hospitals should use recent guidance, such as from the US Agency for Healthcare Research and Quality, and consider pragmatic measurement approaches to start identifying and learning from diagnostic errors.30To reduce cognitive errors, ‘cognitive debiasing strategies’ have been widely recommended.31 However, there is increasing evidence that those strategies are not effective for diagnostic error reduction and recent insights have revealed lack of knowledge as the fundamental cause of errors in the diagnostic reasoning process.32–34 Next steps for practice improvement would therefore need to involve studying the role of knowledge and its interplay with cognitive processes. Interventions should explore what do i need to buy zithromax opportunities to increase clinicians’ knowledge base (eg, by education and feedback) as well as testing and implementing clinical decision support systems to allow for timely access to the relevant knowledge. While specific interventions need more development and testing, other general safety practices such as better collaboration with the laboratory and radiology departments to facilitate more accurate ordering and interpretation of the tests,33 are ready for adoption.ConclusionsTwo studies6 7 of diagnostic error in hospital medicine—by Gunderson and colleagues and Raffel and colleagues—have advanced our knowledge about its epidemiology. Consistent with prior studies, a large range of diseases and a whole host of common contributory factors are what do i need to buy zithromax involved.

Although the estimated prevalence of diagnostic error relies on data from prior studies conducted during an era of limited dedicated tools to identify diagnostic errors, these numbers have significant research and practice implications. Measurement science is still evolving but both studies should inspire all hospitals to apply more contemporary methods to identify and what do i need to buy zithromax analyse diagnostic errors for learning and improvement. Given that errors across multiple diseases in multitude of settings have many common contributing factors, disease-agnostic approaches focused on common systems and process contributory factors are likely to have significant benefit and should be emphasised in further research and development efforts.Patient advocates have long called for patients to have access to all of their healthcare data, including electronic health records (EHRs).1 In parallel, experts have suggested that providing patients with access to EHRs will improve patient engagement, care quality, and, by what do i need to buy zithromax extension, health/healthcare outcomes.2 Prior observational studies have supported some of these claims—for example, documenting that patients are overwhelmingly interested in and satisfied with receiving their healthcare data electronically,3 to finding that patients do identify errors when they read physician notes in the EHR.4 Because studies of EHR access for patients have been conducted and disseminated across disparate clinical conditions and settings and often using varied methodologies, the systematic review by Neves et al in this issue of BMJ Quality &. Safety provides a valuable contribution in assessing the impact of patients’ EHR access specifically within the randomised controlled trial (RCT) literature.5 Their meta-analysis demonstrates some significant but potentially limited benefits within these 20 RCTs that involved sharing EHR data/access with patients.Overall, Neves et al found a few clear trends. First, there was a consistent, modest improvement in glycaemic control in RCTs targeting patients with diabetes, reinforcing the observational research focused on portal use for diabetes care.6 In addition, patient access to EHRs seemed to support safety of care in facilitating medication adherence and identification what do i need to buy zithromax of medication discrepancies.

These results are similar to observational studies,7 as well as a recent scoping review of patient engagement interventions to promote the safety of care and to improve short-term and intermediate-term clinical outcomes.8 Finally, for patient-reported outcomes ranging from self-efficacy to patient activation to patient satisfaction, what do i need to buy zithromax results were mixed, with about half of included studies showing some improvement. Thus, this review highlighted a wide variation and potential lack of consensus about what patient-centred outcome to include in studying EHR-enabled interventions, given the diffuse set of behaviours that could be targeted. More importantly, this review highlights that none of the included studies, many of which are older, focused on equity as a primary objective of the work (and very few even included data on racial/ethnic, educational attainment, digital literacy and/or health literacy differences9 10)—even though there are known barriers to digital health interventions by these characteristics.Despite the modest benefits seen in these 20 randomised trials of EHR-facilitated complex care interventions, we still believe in the what do i need to buy zithromax clinical value and potential improvement in patient-reported outcomes in this space. A more careful examination of the 20 included studies in this review actually sheds important light on delivering complex interventions to improve quality of care, during which patient access to EHRs was implemented in varied ways that might have led to more muddled results. For example, many of the included studies tested evidence-based practices that are known to independently enhance the quality of care, such as patient outreach and reminders for healthcare tasks, self-management training what do i need to buy zithromax and increased healthcare provider communication access.

Therefore, without detailed behavioural pathways for the targeted intervention components surrounding EHR data access, it is challenging to interpret observed trial effects what do i need to buy zithromax. In our opinion and in our previous work,11 one-time action by systems or clinics granting patient access to EHRs is unlikely to replicate the effect of these interventions. In particular, access versus training to use EHRs should likely be considered separately, as well as the study what do i need to buy zithromax of specific features within the EHR. For example, passive provision of medical information from the EHR via online portals (eg, after-visit summaries or list of immunisations) differs substantially from active communication or completion of healthcare tasks via EHR-linked websites (eg, secure messaging exchanges between patients and providers about medical concerns or medication refill requests).Therefore, we hope that this review can push the field beyond RCTs of patient access to EHR data and into specific mechanisms for patient uptake/use that could be more generalisable. First and foremost, it is now generally accepted that patients have what do i need to buy zithromax the right to view their own health data, both because of their ownership of that information and the convenience it may offer.

This indicates that it will likely be impossible to randomise patients to either receive or not receive EHR data in the future, and interventions surrounding universal EHR data access could be more what do i need to buy zithromax specific to targeted behaviours. For example, now that patient electronic access to data is here to stay, future attention to research methods that tailor interventions, tease apart core implementation strategies, and engage patients and providers in codesign will be important next steps to ensure efficiency and relevance. Finally, and perhaps most importantly, RCT participants often differ significantly from target populations, with volunteers often exhibiting higher educational attainment what do i need to buy zithromax and less racial/ethnic diversity.12 Given known disparities in patient EHR access by race/ethnicity, socioeconomic status and health literacy mentioned previously, these trials are not likely to generalise to more diverse populations.Moving forward, the results of this review highlight several principles for future studies of technology-facilitated healthcare delivery. First, all studies need to both include diverse participants and report on race, ethnicity, educational attainment, and health and digital literacy.13 Second, future work must focus on both internal and external validity of patient access/use of EHR data. The review by Neves et al gives us some clearer understanding of the internal validity of studies on clinical and what do i need to buy zithromax patient-reported outcomes, but it remains unclear what impact these types of interventions will have on health outcomes across an entire healthcare system or region outside of RCT samples.

Studies of patient EHR access/use can move into what do i need to buy zithromax the external validity space (even while conducting RCTs)14 by including implementation outcomes, such as the proportion of individuals offered EHR access who take it up, the extent of use over time, the type/features used, and costs for providers and staff, in addition to effectiveness in promoting health outcomes and differences across socioeconomic status, racial/ethnic groups and literacy levels.Like patient advocates and experts for many years, we absolutely agree that patient records belong to patients and should be readily available in structured, electronic form for patients and families.15 Given the complexity of the information provided and the specific context for interacting or supporting patients in completing tasks via online patient portals/platforms, we should not expect access alone to ameliorate current gaps in care or significantly improve morbidity and mortality. As more care becomes digital-first (ie, with virtual care and telemedicine), there are real concerns about widening healthcare disparities for low-income, racial–ethnic minority and linguistically diverse populations. Our specific recommendations what do i need to buy zithromax to avoid such undesirable developments moving forward includeWider measurement of patient interest and access/skills to using technology-based health platforms and tools.Tailoring of interventions to match patient preferences and needs, such as by digital literacy skills as well as inclusion of caregivers/families to support use.Use of mixed method and implementation science studies to understand use, usability, and uptake alongside clinical impact and effectiveness.Attention to these points will allow us to understand the ways in which patient portals and other forms of EHR access for patients may produce different impacts across distinct patient groups. This understanding will not only mitigate potential adverse effects for vulnerable groups but also achieve the intended goal of improving healthcare quality for all patients through freer access to information about their care..

Diagnostic errors in hospital medicine have mostly remained in uncharted waters.1 This is partly because several where to buy generic zithromax factors make measurement of diagnostic errors challenging. Patients are often admitted to hospitals with a tentative diagnosis and need additional where to buy generic zithromax diagnostic investigations to determine next steps. This evolving nature of a diagnosis makes it hard to determine when the correct diagnosis could have been established and if a more specific diagnosis was needed to start the right treatment.2 Hospitalised patients also may have diagnoses that are atypical or rare and pose dilemmas for treating clinicians.

As a result, delays in diagnosis where to buy generic zithromax may not necessarily be related to a diagnostic error. Furthermore, what types of diagnostic errors occur in the hospital where to buy generic zithromax and their prevalence depends on how one defines them. Different approaches to define them have included counting missed, wrong or delayed diagnoses regardless of whether there was a process error;3 counting them only when there was a clear ‘missed opportunity’ – ie, something different could have been done to make the correct or timely diagnosis;4 or diagnostic adverse events (ie, diagnostic errors resulting in harm);5 all leading to views of the problem through different lenses.Two articles in this issue of the journal provide new insights into the epidemiology of diagnostic errors in hospitalised patients.6 7 Gunderson and colleagues conducted a systematic review to determine the prevalence of harmful diagnostic errors in hospitalised patients.6 Raffel and colleagues studied readmitted patients using established methods for diagnostic error detection and analysis to gain insights into contributing factors.7 Both studies advance the science of measurement and understanding of how to reduce diagnostic error in hospitals.

We discuss the significance of the results for hospital medicine and implications for emerging research and practice improvement efforts.Finding diagnostic errors in hospitalsGunderson and colleagues where to buy generic zithromax performed a systematic review and meta-analysis to inform a new estimate for the prevalence of diagnostic adverse events among hospitalised patients, a rate of 0.7%.6 Their review shows how diagnostic error is a global problem, with studies from countries across five continents. The prevalence however is lower than what might be expected looking at previous research, mostly in outpatient care, and based on expert estimates.8–11 The prevalence of diagnostic error in hospital care may be lower because outpatient care, especially primary care, has the challenging task of identifying patients with a serious disease from a large sample of patients who present with common symptoms and mostly benign non-urgent diseases. A higher state of attention in the hospital and higher prior probability of where to buy generic zithromax a patient having a more serious disease may also reduce the likelihood of something being missed (ie, the prevalence effect).12 13 Furthermore, the hospital setting offers more diagnostic evaluation possibilities (consultations, imaging, laboratory) and more members of the diagnostic team to alert a clinician on the wrong diagnostic track.The heterogeneity of the studies in the review and meta-analysis and a broad scope may also explain the lower prevalence rate.6 14 The included studies did not have an exclusive focus on detecting diagnostic errors but rather aimed to identify all types of adverse events, including medication and surgical adverse events,5 15 which are relatively easier to measure.

Consequently, the data collection instruments were likely not where to buy generic zithromax sufficiently sensitive to pick up diagnostic adverse events, resulting in an underestimation. Some diagnostic adverse events may also be classified as ‘other’ types. For instance delayed diagnosis of a wound leakage after surgery is often considered a surgical complication and not categorised as a delay in diagnosis.16 Studies in the review also detected adverse events (ie, errors that where to buy generic zithromax resulted in harm)6 which is a subgroup of diagnostic errors, because not every diagnostic error results in harm.17 Lastly, while the random selection of patients is a strength for determining prevalence of medical error, not all admissions involve making a diagnosis—patients are often hospitalised for treatment and procedures.

As the literature in the area becomes more robust, future reviews may be able to provide an updated estimate. For now, Gunderson and colleagues estimate 250,000 diagnostic adverse where to buy generic zithromax events occur annually in the USA, which should be alarming enough to warrant attention and intervention.While the study by Raffel and colleagues is not a true prevalence study (it only evaluated 7-day readmissions), it uses dedicated tools to identify diagnostic error in hospitals, a crucial next step. By examining a subset of hospital admissions at greater risk of diagnosis-related problems (ie, readmissions within 7 days after hospital discharge) and by using tools dedicated to identifying where to buy generic zithromax diagnostic error, the investigators were able to describe error types and contributing factors.

The advantage of studying such a high-risk sample is that diagnostic errors can be found more efficiently, that is, the positive predictive value is higher than if you review all consecutive patients. This could identify where to buy generic zithromax a higher number of cases to identify contributing factors. While the positive predictive value they achieved through this method was still rather low, methods to selectively identify diagnostic errors are valuable in measurement efforts.

Future studies could build on this work to develop sampling methods with higher predictive values that can be used by others for research and practice improvement.Diseases at risk for diagnostic error in the hospital settingTypes of conditions involved in diagnostic error in both studies reflect a broad range of diseases commonly identified in previous studies, such as malignancies, pulmonary embolism, aortic aneurysm and s.5 8 18 A recent where to buy generic zithromax malpractice claims-based study has led some to suggest that initial diagnostic error reduction efforts, including allocation of funding for research and quality measurement/improvement, should focus on three broad types of disease categories, the so-called ‘Big Three’, namely cancer, s and cardiovascular diseases, because they are highly prevalent and result in significant harm.11 19 20 These three disease categories cover a large portion of diagnoses made in medicine. Indeed, data beyond claims also suggest that diagnostic errors in each of these categories are common.5 18 However, diagnostic errors span a large range of other diseases as shown in both studies, which where to buy generic zithromax is similar to what prior studies have found. For instance, in one primary care study, 68 unique diagnoses were missed with the most common condition accounting for only 6.7% of errors.21Contributing factors in hospital medicineRaffel and colleagues applied established tools (ie, SAFER Dx22 and DEER23) to identify contributing factors.

They found where to buy generic zithromax that most of these involved failures in clinical assessment and/or testing. Contributing factors in these two domains occurred in more than 90% of diagnostic errors, a high proportion consistent with previous work.8 17 18 Furthermore, these main where to buy generic zithromax contributing factors are common across diagnostic errors regardless of the diseases involved. For instance, similar process breakdowns emerge across different types of missed cancer diagnoses.24–26Finding ‘Forests’ not just the ‘Big Trees’ to enable scientific progressSo should initial scientific efforts just target disease categories?.

And if so, should they where to buy generic zithromax address just the ‘Big Three’?. Data from prior studies across different settings, including those from Gunderson and Raffel and colleagues, find large diversity in misdiagnosed diseases.5–7 18 21 27 This suggests that an exclusive focus on the ‘Big Three’ would neglect a substantial proportion of other common and harmful diagnostic errors.27 Furthermore, research on contributing factors of diagnostic errors reveals a number of common system and process factors that would require robust disease-agnostic approaches. If funding and advocacy for diagnostic safety becomes mostly disease oriented, it will pull resources away from broader ‘disease-agnostic’ research and quality improvement efforts needed to understand and address these underlying system and process factors.28 Biomedical research is already quite disease focused and supported by many disease-specific institutes and this now needs to be balanced by work that catalyses much-needed foundational and cross-cutting healthcare delivery system improvements.We would thus recommend a balanced strategy that carefully combines disease-specific and disease-agnostic approaches to help address common contributing factors, system issues and process breakdowns for diagnostic error that cut across these where to buy generic zithromax many unique diseases.

For example, if new quality measures to quantify delays in colorectal cancer diagnosis and missed diagnosis of sepsis are developed, we would also where to buy generic zithromax need ‘disease-agnostic’ studies that evaluate the implementation and effectiveness of such measures. This includes how they fit within current measurement programmes, what their measurement burden is and what the unintended consequences may be. A combined approach would create where to buy generic zithromax more synergistic and collaborative understanding in addition to enabling application of common frameworks and approaches to multiple conditions, rather than ‘reinventing the wheel’ for each disease or disease category.

This type of approach may have a larger population-based impact and help us see the entire ‘forest’ to reduce diagnostic error.Implications for practice improvementA crucial first step for improving diagnosis in hospitals is to create programmes to identify and analyse diagnostic errors.29 Most hospitals have systems and programmes in place to report and analyse safety issues such as falls, surgical complications and medication errors, but they do not capture diagnostic errors. With increased recognition of risks for diagnostic error, hospitals should use recent guidance, such as from the US Agency for Healthcare Research and Quality, and consider pragmatic measurement approaches to start identifying and learning from diagnostic errors.30To reduce cognitive errors, ‘cognitive debiasing strategies’ have been widely recommended.31 However, there is increasing evidence that those strategies are not effective for diagnostic error reduction and recent insights have revealed lack of knowledge as the fundamental cause of errors in the diagnostic reasoning process.32–34 Next steps for practice improvement would therefore need to involve studying the role of knowledge and its interplay with where to buy generic zithromax cognitive processes. Interventions should explore opportunities to increase clinicians’ knowledge base (eg, by education and feedback) as well as testing where to buy generic zithromax and implementing clinical decision support systems to allow for timely access to the relevant knowledge.

While specific interventions need more development and testing, other general safety practices such as better collaboration with the laboratory and radiology departments to facilitate more accurate ordering and interpretation of the tests,33 are ready for adoption.ConclusionsTwo studies6 7 of diagnostic error in hospital medicine—by Gunderson and colleagues and Raffel and colleagues—have advanced our knowledge about its epidemiology. Consistent with prior studies, a large range of diseases and a where to buy generic zithromax whole host of common contributory factors are involved. Although the estimated prevalence of diagnostic error relies on data from prior studies conducted during an era of limited dedicated tools to identify diagnostic errors, these numbers have significant research and practice implications.

Measurement science is still evolving but both studies should inspire all hospitals to apply where to buy generic zithromax more contemporary methods to identify and analyse diagnostic errors for learning and improvement. Given that errors across multiple diseases in multitude of settings have many common contributing factors, disease-agnostic approaches focused on common systems and process contributory factors are likely to have significant benefit and should be emphasised in further research and development efforts.Patient advocates have long called for patients to have access to all of their healthcare data, including where to buy generic zithromax electronic health records (EHRs).1 In parallel, experts have suggested that providing patients with access to EHRs will improve patient engagement, care quality, and, by extension, health/healthcare outcomes.2 Prior observational studies have supported some of these claims—for example, documenting that patients are overwhelmingly interested in and satisfied with receiving their healthcare data electronically,3 to finding that patients do identify errors when they read physician notes in the EHR.4 Because studies of EHR access for patients have been conducted and disseminated across disparate clinical conditions and settings and often using varied methodologies, the systematic review by Neves et al in this issue of BMJ Quality &. Safety provides a valuable contribution in assessing the impact of patients’ EHR access specifically within the randomised controlled trial (RCT) literature.5 Their meta-analysis demonstrates some significant but potentially limited benefits within these 20 RCTs that involved sharing EHR data/access with patients.Overall, Neves et al found a few clear trends.

First, there was a consistent, modest improvement in glycaemic control in RCTs targeting patients with diabetes, reinforcing the observational research focused on portal use for diabetes care.6 In addition, patient access to EHRs seemed where to buy generic zithromax to support safety of care in facilitating medication adherence and identification of medication discrepancies. These results are similar to observational studies,7 as well as a recent scoping review of patient engagement interventions to promote the safety of care and to improve short-term and intermediate-term clinical outcomes.8 Finally, for patient-reported outcomes ranging from self-efficacy to patient activation to patient satisfaction, results were mixed, with where to buy generic zithromax about half of included studies showing some improvement. Thus, this review highlighted a wide variation and potential lack of consensus about what patient-centred outcome to include in studying EHR-enabled interventions, given the diffuse set of behaviours that could be targeted.

More importantly, where to buy generic zithromax this review highlights that none of the included studies, many of which are older, focused on equity as a primary objective of the work (and very few even included data on racial/ethnic, educational attainment, digital literacy and/or health literacy differences9 10)—even though there are known barriers to digital health interventions by these characteristics.Despite the modest benefits seen in these 20 randomised trials of EHR-facilitated complex care interventions, we still believe in the clinical value and potential improvement in patient-reported outcomes in this space. A more careful examination of the 20 included studies in this review actually sheds important light on delivering complex interventions to improve quality of care, during which patient access to EHRs was implemented in varied ways that might have led to more muddled results. For example, many of the included studies tested evidence-based practices that are known to independently enhance the quality of care, such as patient outreach and reminders for healthcare tasks, self-management training and where to buy generic zithromax increased healthcare provider communication access.

Therefore, without detailed behavioural pathways for the targeted intervention components surrounding EHR data access, it is challenging to interpret observed trial effects where to buy generic zithromax. In our opinion and in our previous work,11 one-time action by systems or clinics granting patient access to EHRs is unlikely to replicate the effect of these interventions. In particular, access versus training to use EHRs should likely be considered separately, as well as the study of specific features within the EHR where to buy generic zithromax.

For example, passive provision of medical information from the EHR via online portals (eg, after-visit summaries or list of immunisations) differs substantially from active communication or completion of healthcare tasks via EHR-linked websites (eg, secure messaging exchanges between patients and providers about medical concerns or medication refill requests).Therefore, we hope that this review can push the field beyond RCTs of patient access to EHR data and into specific mechanisms for patient uptake/use that could be more generalisable. First and foremost, it is now generally accepted that patients have the right to view their own health data, both because of their ownership of that information and the convenience where to buy generic zithromax it may offer. This indicates that it will likely be impossible to randomise patients to either where to buy generic zithromax receive or not receive EHR data in the future, and interventions surrounding universal EHR data access could be more specific to targeted behaviours.

For example, now that patient electronic access to data is here to stay, future attention to research methods that tailor interventions, tease apart core implementation strategies, and engage patients and providers in codesign will be important next steps to ensure efficiency and relevance. Finally, and perhaps most importantly, RCT participants often differ significantly from target populations, with volunteers often exhibiting higher educational attainment and less racial/ethnic diversity.12 Given where to buy generic zithromax known disparities in patient EHR access by race/ethnicity, socioeconomic status and health literacy mentioned previously, these trials are not likely to generalise to more diverse populations.Moving forward, the results of this review highlight several principles for future studies of technology-facilitated healthcare delivery. First, all studies need to both include diverse participants and report on race, ethnicity, educational attainment, and health and digital literacy.13 Second, future work must focus on both internal and external validity of patient access/use of EHR data.

The review by Neves et al gives us some clearer understanding of the internal validity of studies on clinical and patient-reported outcomes, but it remains unclear what impact these types of interventions will have on health outcomes across an entire healthcare system or region outside of RCT where to buy generic zithromax samples. Studies of patient EHR access/use can move into the external validity space (even while conducting RCTs)14 by including implementation outcomes, such as the proportion of individuals offered EHR access who take it up, the extent of use over time, the type/features used, and costs for providers and staff, in addition to effectiveness in promoting health outcomes and differences across socioeconomic status, racial/ethnic groups and literacy levels.Like patient advocates and experts for many years, we absolutely agree that patient records belong to patients and should be readily available in structured, electronic form for patients and families.15 Given the complexity of the information provided and the specific context where to buy generic zithromax for interacting or supporting patients in completing tasks via online patient portals/platforms, we should not expect access alone to ameliorate current gaps in care or significantly improve morbidity and mortality. As more care becomes digital-first (ie, with virtual care and telemedicine), there are real concerns about widening healthcare disparities for low-income, racial–ethnic minority and linguistically diverse populations.

Our specific recommendations to avoid such undesirable developments moving forward includeWider measurement of patient interest and access/skills to using technology-based health platforms and tools.Tailoring of interventions to match patient preferences and needs, such as by digital literacy skills as well as inclusion of caregivers/families to support use.Use of mixed method where to buy generic zithromax and implementation science studies to understand use, usability, and uptake alongside clinical impact and effectiveness.Attention to these points will allow us to understand the ways in which patient portals and other forms of EHR access for patients may produce different impacts across distinct patient groups. This understanding will not only mitigate potential adverse effects for vulnerable groups but also achieve the intended goal of improving healthcare quality for all patients through freer access to information about their care..

What side effects may I notice from Zithromax?

Side effects that you should report to your prescriber or health care professional as soon as possible:

  • dark yellow or brown urine;
  • difficulty breathing; severe or watery diarrhea;
  • skin rash, itching;
  • irregular heartbeat, palpitations, or chest pain;
  • vomiting;
  • yellowing of the eyes or skin

Side effects that usually do not require medical attention (report to your prescriber or health care professional if they continue or are bothersome):

  • diarrhea;
  • dizziness, drowsiness;
  • hearing loss;
  • headache;
  • increased sensitivity to the sun;
  • nausea;
  • stomach pain or cramps;
  • tiredness;
  • vaginal irritation, itching or discharge

This list may not describe all possible side effects.

Zithromax amoxicillin

Dr How to get viagra in the us zithromax amoxicillin. Scott Gottlieb told CNBC on Tuesday the rollout zithromax amoxicillin of buy antibiotics treatments in the U.S. May eventually be slowed by not enough people wanting to receive zithromax amoxicillin the shot.While the incoming Biden administration will initially be focused on increasing access to treatments, Gottlieb said public-health efforts also must combat concerns held by some Americans."I think we need to also ....

Work on the demand side of this equation. We can't lose sight of that and just take for granted that everyone wants this treatment," the former Food and Drug Administration commissioner zithromax amoxicillin said "Squawk Box."President-elect Joe Biden, who takes office Wednesday, has pledged to vaccinate 100 million people in 100 days. Last week, Biden offered more details on his plan to do zithromax amoxicillin so, which includes having the Federal Emergency Management Agency and National Guard build antibiotics treatment clinics across the United States.

Biden also intends to accelerate the timeline for when buy antibiotics treatments could be available at pharmacies.Biden's plan to address the slower-than-expected treatment rollout is an "all-of-the-above approach, and then you see what's working," said Gottlieb, who led the FDA from 2017 to 2019 under President Donald Trump. Gottlieb now serves on the board of Pfizer, which makes one zithromax amoxicillin of the two treatments to receive emergency use authorization from the FDA. The other is made by Moderna."We've talked about access being the real challenge right now, and now we're talking about supply because we're starting to get to a steady state of supply zithromax amoxicillin and it's hard to increase the supply in the near term," Gottlieb said.

"At some point, demand is going to be come an issue."Currently, demand for antibiotics treatments remains strong because older Americans have become eligible for shots, Gottlieb said. With age being a key risk making people more vulnerable to becoming hospitalized, or potentially, dying from zithromax amoxicillin buy antibiotics, those Americans appear rather willing to take the treatment."There's going to be a lot of intense demand even in younger cohorts, but I think once we get to 100 million, maybe 120 million treatments, the demand is going to get soft," Gottlieb said, basing his forecast on the number of U.S. Adults who received a flu shot this past year."Those were people who zithromax amoxicillin were worried about getting buy antibiotics going out and getting flu treatments.

That may be the universe of people who really have significant demand for a buy antibiotics treatment," he added.Biden has sought to assure Americans about the safety and efficacy of buy antibiotics treatments in an effort to increase the number of people who are willing to receive the shot. In December, after getting his first shot of the two-dose Pfizer treatment on live television, Biden said there is "nothing to worry about."About zithromax amoxicillin 12.3 million Americans have received their initial treatment dose as of Friday morning, according to the latest available data compiled by the Centers for Disease Control and Prevention. Roughly 31.2 zithromax amoxicillin million doses have been distributed.buy antibiotics treatments play a critical role in helping the U.S.

And the world combat the devastating zithromax. In the zithromax amoxicillin U.S. Alone, there has zithromax amoxicillin been nearly 24.1 million confirmed antibiotics cases and at least 399,008 deaths from buy antibiotics, according to data compiled by Johns Hopkins University.The zithromax also has caused significant economic damage, as millions of people have lost their jobs and businesses have closed across the U.S.

Widespread vaccinations against buy antibiotics are seen as critical in allowing a more robust economic recovery and for the stock market. For example, in a week-ahead note to clients, JPMorgan zithromax amoxicillin analysts wrote, "Going forward, the biggest macro risk appears to be treatment supply, distribution and uptake."Disclosure. Scott Gottlieb zithromax amoxicillin is a CNBC contributor and is a member of the boards of Pfizer, genetic testing start-up Tempus and biotech company Illumina.

He also serves as co-chair of Norwegian Cruise Line Holdings' and Royal Caribbean's "Healthy Sail Panel."Here are the most important news, trends and analysis that investors need to start their trading day:1. Dow set to resume its winning waysThis combination of pictures created zithromax amoxicillin on January 15, 2021 shows US President Donald Trump at the White House in Washington, DC, on July 29, 2020 and Democratic presidential nominee and former Vice President Joe Biden in Dallas, Pennsylvania, on October 24, 2020.Getty Images2. Yellen goes before Senate panel for zithromax amoxicillin confirmation hearingU.S.

Secretary of the Treasury nominee Janet Yellen speaks during an event to name President-elect Joe Biden’s economic team at the Queen Theater on December 1, 2020 zithromax amoxicillin in Wilmington, Delaware.Alex Wong | Getty ImagesJanet Yellen, Biden's nominee for Treasury secretary, will tell the Senate Finance Committee on Tuesday that the government must "act big" with its next antibiotics relief measure. The president-elect outlined a $1.9 trillion stimulus package last week. In prepared testimony for her confirmation hearing, zithromax amoxicillin the former Fed chief also said the U.S.

Economy must be rebuilt "so that it creates zithromax amoxicillin more prosperity for more people."3. Biden's planned 10-day blitz of executive actionSignage for the Presidential inauguration on a barrier outside the White House in Washington, D.C., U.S., on Monday, Jan. 18, 2021.Al Drago | Bloomberg | Getty ImagesBiden is planning on a 10-day blitz of executive action on what his administration is calling the zithromax amoxicillin "four crises" facing the country.

buy antibiotics, the economic downturn, racial injustice zithromax amoxicillin and climate change. Biden chief of staff Ron Klain told CNN on Sunday the president-elect is going to come back to the White House after his inauguration and "take some immediate actions to move the country forward." Klain also said Biden's inaugural address would be "a message of moving this country forward, a message of unity, a message of getting things done."4. buy antibiotics memorial zithromax amoxicillin set as U.S.

zithromax deaths near 400,000The "Field of zithromax amoxicillin Flags" is illuminated on the National Mall as the U.S Capitol Building is prepared for the inauguration of President-elect Joe Biden, in Washington, U.S., January 18, 2021.Joe Raedle | ReutersBiden's inauguration committee is set to hold a memorial to remember the lives lost to buy antibiotics on Tuesday evening in Washington as U.S. Deaths from the antibiotics neared 400,000. The president-elect zithromax amoxicillin is expected to speak at the commemoration.

On Monday, the incoming Biden administration said it won't lift an entry ban on most visitors from Europe and zithromax amoxicillin Brazil, shortly after Trump ordered an end to those travel restrictions. The outgoing president first put the buy antibiotics rules in place in March.5. Senate awaits Trump impeachment articleU.S zithromax amoxicillin.

National Guard riot shields are zithromax amoxicillin laid out at the ready outside the U.S. Capitol Building on Capitol Hill in Washington, U.S., January 13, 2021.Jim Bourg | ReutersThe Senate, which returns Tuesday, awaits the transfer of the single article of impeachment against Trump for inciting the Jan. 6 attack zithromax amoxicillin on the U.S.

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Follow all the developments on Wall Street in real time with CNBC Pro's live markets blog. Get the latest on the zithromax with our antibiotics blog..

Dr. Scott Gottlieb told CNBC on Tuesday the rollout of buy antibiotics treatments in the U.S. May eventually be slowed by not enough people wanting to receive the shot.While the incoming Biden administration will initially be focused on increasing access to treatments, Gottlieb said public-health efforts also must combat concerns held by some Americans."I think we need to also ....

Work on the demand side of this equation. We can't lose sight of that and just take for granted that everyone wants this treatment," the former Food and Drug Administration commissioner said "Squawk Box."President-elect Joe Biden, who takes office Wednesday, has pledged to vaccinate 100 million people in 100 days. Last week, Biden offered more details on his plan to do so, which includes having the Federal Emergency Management Agency and National Guard build antibiotics treatment clinics across the United States.

Biden also intends to accelerate the timeline for when buy antibiotics treatments could be available at pharmacies.Biden's plan to address the slower-than-expected treatment rollout is an "all-of-the-above approach, and then you see what's working," said Gottlieb, who led the FDA from 2017 to 2019 under President Donald Trump. Gottlieb now serves on the board of Pfizer, which makes one of the two treatments to receive emergency use authorization from the FDA. The other is made by Moderna."We've talked about access being the real challenge right now, and now we're talking about supply because we're starting to get to a steady state of supply and it's hard to increase the supply in the near term," Gottlieb said.

"At some point, demand is going to be come an issue."Currently, demand for antibiotics treatments remains strong because older Americans have become eligible for shots, Gottlieb said. With age being a key risk making people more vulnerable to becoming hospitalized, or potentially, dying from buy antibiotics, those Americans appear rather willing to take the treatment."There's going to be a lot of intense demand even in younger cohorts, but I think once we get to 100 million, maybe 120 million treatments, the demand is going to get soft," Gottlieb said, basing his forecast on the number of U.S. Adults who received a flu shot this past year."Those were people who were worried about getting buy antibiotics going out and getting flu treatments.

That may be the universe of people who really have significant demand for a buy antibiotics treatment," he added.Biden has sought to assure Americans about the safety and efficacy of buy antibiotics treatments in an effort to increase the number of people who are willing to receive the shot. In December, after getting his first shot of the two-dose Pfizer treatment on live television, Biden said there is "nothing to worry about."About 12.3 million Americans have received their initial treatment dose as of Friday morning, according to the latest available data compiled by the Centers for Disease Control and Prevention. Roughly 31.2 million doses have been distributed.buy antibiotics treatments play a critical role in helping the U.S.

And the world combat the devastating zithromax. In the U.S. Alone, there has been nearly 24.1 million confirmed antibiotics cases and at least 399,008 deaths from buy antibiotics, according to data compiled by Johns Hopkins University.The zithromax also has caused significant economic damage, as millions of people have lost their jobs and businesses have closed across the U.S.

Widespread vaccinations against buy antibiotics are seen as critical in allowing a more robust economic recovery and for the stock market. For example, in a week-ahead note to clients, JPMorgan analysts wrote, "Going forward, the biggest macro risk appears to be treatment supply, distribution and uptake."Disclosure. Scott Gottlieb is a CNBC contributor and is a member of the boards of Pfizer, genetic testing start-up Tempus and biotech company Illumina.

He also serves as co-chair of Norwegian Cruise Line Holdings' and Royal Caribbean's "Healthy Sail Panel."Here are the most important news, trends and analysis that investors need to start their trading day:1. Dow set to resume its winning waysThis combination of pictures created on January 15, 2021 shows US President Donald Trump at the White House in Washington, DC, on July 29, 2020 and Democratic presidential nominee and former Vice President Joe Biden in Dallas, Pennsylvania, on October 24, 2020.Getty Images2. Yellen goes before Senate panel for confirmation hearingU.S.

Secretary of the Treasury nominee Janet Yellen speaks during an event to name President-elect Joe Biden’s economic team at the Queen Theater on December 1, 2020 in Wilmington, Delaware.Alex Wong | Getty ImagesJanet Yellen, Biden's nominee for Treasury secretary, will tell the Senate Finance Committee on Tuesday that the government must "act big" with its next antibiotics relief measure. The president-elect outlined a $1.9 trillion stimulus package last week. In prepared testimony for her confirmation hearing, the former Fed chief also said the U.S.

Economy must be rebuilt "so that it creates more prosperity for more people."3. Biden's planned 10-day blitz of executive actionSignage for the Presidential inauguration on a barrier outside the White House in Washington, D.C., U.S., on Monday, Jan. 18, 2021.Al Drago | Bloomberg | Getty ImagesBiden is planning on a 10-day blitz of executive action on what his administration is calling the "four crises" facing the country.

buy antibiotics, the economic downturn, racial injustice and climate change. Biden chief of staff Ron Klain told CNN on Sunday the president-elect is going to come back to the White House after his inauguration and "take some immediate actions to move the country forward." Klain also said Biden's inaugural address would be "a message of moving this country forward, a message of unity, a message of getting things done."4. buy antibiotics memorial set as U.S.

zithromax deaths near 400,000The "Field of Flags" is illuminated on the National Mall as the U.S Capitol Building is prepared for the inauguration of President-elect Joe Biden, in Washington, U.S., January 18, 2021.Joe Raedle | ReutersBiden's inauguration committee is set to hold a memorial to remember the lives lost to buy antibiotics on Tuesday evening in Washington as U.S. Deaths from the antibiotics neared 400,000. The president-elect is expected to speak at the commemoration.

On Monday, the incoming Biden administration said it won't lift an entry ban on most visitors from Europe and Brazil, shortly after Trump ordered an end to those travel restrictions. The outgoing president first put the buy antibiotics rules in place in March.5. Senate awaits Trump impeachment articleU.S.

National Guard riot shields are laid out at the ready outside the U.S. Capitol Building on Capitol Hill in Washington, U.S., January 13, 2021.Jim Bourg | ReutersThe Senate, which returns Tuesday, awaits the transfer of the single article of impeachment against Trump for inciting the Jan. 6 attack on the U.S.

Capitol. Trump's impeachment trial won't likely begin until after he leaves office. The Republicans still call the shots in the Senate until Georgia's two new Democratic senators are sworn in, which will then flip the majority in the chamber with 50-50 split and Vice President-elect Kamala Harris as the tie-breaking vote.— The Associated Press and Reuters.

Follow all the developments on Wall Street in real time with CNBC Pro's live markets blog. Get the latest on the zithromax with our antibiotics blog..

Zithromax gonorrhea and chlamydia treatment

Credit http://cz.keimfarben.de/best-online-cialis zithromax gonorrhea and chlamydia treatment. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and zithromax gonorrhea and chlamydia treatment is the most common form of permanent alopecia in this population. The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair zithromax gonorrhea and chlamydia treatment loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries.

During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over. The prevalence of those with fibroids was compared in patients with and without CCCA zithromax gonorrhea and chlamydia treatment. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids. The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, zithromax gonorrhea and chlamydia treatment compared to age, sex and race matched controls.

Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the zithromax gonorrhea and chlamydia treatment two conditions remains unclear,” she says. However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with zithromax gonorrhea and chlamydia treatment excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on this paper zithromax gonorrhea and chlamydia treatment were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit. The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors zithromax gonorrhea and chlamydia treatment across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors.

- Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new zithromax gonorrhea and chlamydia treatment study led by Johns Hopkins Kimmel Cancer Center researchers shows. The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide zithromax gonorrhea and chlamydia treatment future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells. As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an .

These medicines have had remarkable success in treating some types of cancers that historically have had poor zithromax gonorrhea and chlamydia treatment prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma. The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow zithromax gonorrhea and chlamydia treatment. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the zithromax gonorrhea and chlamydia treatment mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined zithromax gonorrhea and chlamydia treatment these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation. The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer zithromax gonorrhea and chlamydia treatment.

€œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive. It’s one of those things that doesn’t sound right when you hear it,” says zithromax gonorrhea and chlamydia treatment Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare zithromax gonorrhea and chlamydia treatment and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors. However, he explains, this cancer type is often caused by a zithromax, which seems to encourage a strong immune response despite the cancer’s lower mutational burden.

In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these zithromax gonorrhea and chlamydia treatment findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried. Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of zithromax gonorrhea and chlamydia treatment immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the zithromax gonorrhea and chlamydia treatment Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit Best online cialis where to buy generic zithromax. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form where to buy generic zithromax of permanent alopecia in this population.

The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that where to buy generic zithromax may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

The prevalence of those with fibroids was compared in patients with and without where to buy generic zithromax CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

The findings translate where to buy generic zithromax to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause where to buy generic zithromax of the link between the two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with where to buy generic zithromax this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other where to buy generic zithromax authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different where to buy generic zithromax cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s where to buy generic zithromax DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials where to buy generic zithromax for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success where to buy generic zithromax in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

The mutational burden of certain tumor where to buy generic zithromax types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes where to buy generic zithromax to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined where to buy generic zithromax these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be where to buy generic zithromax explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of where to buy generic zithromax those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well where to buy generic zithromax to checkpoint inhibitors.

However, he explains, this cancer type is often caused by a zithromax, which seems to encourage a strong immune response despite the cancer’s lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors where to buy generic zithromax on cancer types for which these drugs haven’t yet been tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Zithromax same as azithromycin

In response to the buy antibiotics zithromax, members of the Rapid Deployment treatment Collaborative (or RaDVaC)—a group composed of scientists and zithromax same as azithromycin their friends or colleagues—have been self-administering an untested treatment for http://charltonsingleton.com/buy-cialis-through-paypal/ antibiotics (the zithromax that causes buy antibiotics). The RaDVaC scientists describe their project as aiming “to reduce risk of harm from antibiotics, minimally until there is at least one effective commercial treatment widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions. Self-experimentation has a fascinating history zithromax same as azithromycin. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the study team as participants.

These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants. Some Nobel Prize–winning work by scientists was based on self-experimentation that initially was seen as zithromax same as azithromycin crazy. For instance, in 1984, Barry Marshall swallowed bacteria to prove that they caused gastritis and peptic ulcers. Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart.

Perhaps surprisingly, self-experimentation was once considered an ethical zithromax same as azithromycin safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies. However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only zithromax same as azithromycin is self-experimentation legally and ethically complex, but protections like independent review and informed consent, which are now required by research regulations, may be a better way to protect research participants.

Existing regulations for research were not designed to address self-experimentation. Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people. In addition, zithromax same as azithromycin the U.S. Common Rule governs federally funded research, and RaDVaC is not using any federal funding.

However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies of immune responses involving self-experimentation are planned in George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, which zithromax same as azithromycin would provide some oversight of this self-experimentation. If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight. The U.S.

Food and Drug Administration has similar zithromax same as azithromycin power to regulate research, and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if they are not distributed for profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key antibiotics proteins—and therefore may fall under the FDA’s jurisdiction. While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people were harmed by taking this treatment, they could also zithromax same as azithromycin sue RaDVaC, but the disclaimers in the white paper are carefully designed to avoid liability.

Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort. If RaDVaC intends to produce generalizable knowledge about this treatment, unsystematic self-experimentation is unlikely to produce useful information. For example, self-experimentation can lead to biased results if researchers overestimate the chance that the treatment zithromax same as azithromycin works, or fail to report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo.

Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this treatment based on these expert’s recommendations, which could lead to two potential misconceptions. First, people taking the treatment might overestimate the likelihood zithromax same as azithromycin that they are protected from antibiotics and change their behavior. If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others. A second misconception is the idea that this is research that could benefit others.

The same data analyst seemed to believe this when he added “my continued existence through this zithromax will be a useful data set.” Yet the RaDVaC project could not produce useful data in the same way as standard, well-designed zithromax same as azithromycin treatment trials, for example, because it is unclear whether individuals receiving the treatment are thoroughly evaluated or monitored, and there does not appear to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege. Senior scientists benefit from many layers of privilege zithromax same as azithromycin. Investment in their education, expertise in specialized areas, and access to information or materials.

Arguably, these privileges come with a responsibility to use expertise for the benefit of society. If the RaDVaC treatment is potentially beneficial, then it is tragic not to test it in zithromax same as azithromycin a rigorously designed study. Indeed, uncontrolled self-experimentation is part of a larger problem in the buy antibiotics zithromax. Panic about the zithromax has led to the widespread use of interventions outside of well-designed clinical trials.

Without such trials, we zithromax same as azithromycin remain in the dark about which interventions offer net benefits or net harms. Insofar as the scientists involved have expertise in treatment research, they should either reform the RaDVaC project or lend their expertise to serious projects. On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful. Earlier this week, Steven Salzberg, a computational biologist, called for zithromax same as azithromycin experimental buy antibiotics treatments to be rolled out before the results of phase III testing.

An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately. Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research. Their time might be better spent on projects in zithromax same as azithromycin these fields, which will still be important when this zithromax is finally over. Rather than trying everything but the kitchen sink against buy antibiotics, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for buy antibiotics.

RaDVaC’s scientists should be encouraged to collaborate on systematic buy antibiotics treatment testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color. The stalagmites zithromax same as azithromycin and stalactites of Goikoetxe Cave are not just the usual white. Many range from honey to deep red. New research shows that these formations, known generally as speleothems, get their red color from organic compounds leached from soil and transported by water.

Scientists suggest, in an article published online in April in Quaternary International, that Goikoetxe Cave's speleothems zithromax same as azithromycin record environmental conditions such as rainfall.The wildfire season is off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage. But that’s just one consequence of global warming. It’s also leading to flooding, torrential rainstorms and heat-related zithromax same as azithromycin deaths.

In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often. I vividly remember a patient who came in late for her appointment during a July heat wave zithromax same as azithromycin. When I walked in, she said, “I’m so sorry I’m late, I was up all night walking my grandbaby around the train station.” Without air conditioning at home, the child was sweating through her clothes in the heat of the night, putting her at risk for dehydration.

July 2019 was the hottest July on record. September 2019 was the zithromax same as azithromycin hottest on record. January 2020 was the hottest on record. May 2020 was the hottest on record.

This is not zithromax same as azithromycin a coincidence. It is a pattern. Carbon dioxide, an important greenhouse gas contributing to global warming, has increased by 9 percent since 2005 and by 31 percent since 1950. A U.N zithromax same as azithromycin.

Intergovernmental Panel on Climate Change special report pointed out that the world has already warmed about one degree Celsius from pre-industrial levels. It stressed the urgency to act to limit warming to 1.5 degrees, and that a two-degree increase will lead to unprecedented extreme heat, zithromax same as azithromycin water scarcity and food shortages around the globe. Heat affects every part of our body. It can lead to heat exhaustion, heat stroke, anxiety, impaired cognitive function and even premature death from heart and lung disease.

Across the country, the health concerns of the climate crisis are increasingly being recognized, pushing thousands of medical providers—doctors, nurses, zithromax same as azithromycin pharmacists, therapists, medical students—to become advocates for change. In my own practice, I explain to patients how the climate crisis affects their health. For example, apart from contributing to global warming, rising carbon dioxide levels increase the amount of pollen that plants produce as a consequence of higher rates of photosynthesis. This rise in pollen levels can lead zithromax same as azithromycin to worsening allergy symptoms.

Another example is fine particulate matter (known as PM2.5) associated with air pollution, much of it linked to the burning of fossil fuels that help drive the warming. When we breathe in these particles, they travel down the airway and settle in the tiny air sacs called alveoli of the lungs, causing inflammation and potentially worsening asthma symptoms. The explanations are simple, but the health zithromax same as azithromycin risks are widespread and complex. Ground-level ozone pollution, which is worse in hotter weather, can also harm people with asthma and other respiratory diseases.

And that harm falls disproportionately on the poor. Wealthier people living in North America have a per capita carbon footprint that is 25 percent higher than those of lower-income residents, with some affluent suburbs producing emissions 15 times zithromax same as azithromycin higher than nearby neighborhoods. These carbon emissions contribute to global warming, and the subsequent health consequences are felt far beyond the neighborhood that produces them. Older adults, children, low-income communities and communities of color are less resilient on average to the health impacts of climate change.

The climate crisis is thus zithromax same as azithromycin leading to a disproportionate public health crisis—and worse, it is a threat multiplier. At a time when many Americans are economically challenged, continued heat waves and the higher energy bills they trigger threaten access to water and energy security. The economic benefits of a low-carbon economy are clear. Estimates suggest that without climate investments, the United States will face economic damage from climate change equivalent to 1–3 percent of zithromax same as azithromycin GDP per year by 2100.

The majority of Americans think global warming is happening. The climate crisis has unfairly been labeled as political, when in fact, people recognize that something needs to be done about it. Even for those who are seemingly unaffected, there is increasing global zithromax same as azithromycin recognition that the safeguards of living in a protected community and affording expert medical care will eventually fail if global warming continues unchecked. Unfortunately, there will be no treatment in six months or a year for the climate crisis.

The only treatment is collective climate action in the present. Climate action zithromax same as azithromycin is required of our elected leaders, and we must mandate it of ourselves. It can be as simple as educating family and friends, while making sustainable shopping and traveling choices. It includes eating less meat, unplugging electronics and raising a voice against the fossil fuel industry.

With a rise in demand for absentee ballots zithromax same as azithromycin for the election this November, it is crucial to request mail-in ballots right away to make sure our voices are heard. The United States is the second largest emitter of greenhouse gases, and we must vote for green policy. Legislative action and policy change work, as evidenced by the Clean Air Act and its subsequent amendments, which are projected to save 230,000 lives in 2020. The climate crisis is a public health issue, and we must start healing the planet in order to heal each zithromax same as azithromycin other.

Fighting against the climate crisis is one of the most patriotic things we can do right now. It will protect our health and the health of our neighbors across the country and the globe, and will allow all of us to live on this planet, the only home we have..

In response to the Buy cialis through paypal buy antibiotics zithromax, members of the Rapid Deployment treatment Collaborative (or RaDVaC)—a group composed of scientists and their friends or colleagues—have been self-administering an untested treatment where to buy generic zithromax for antibiotics (the zithromax that causes buy antibiotics). The RaDVaC scientists describe their project as aiming “to reduce risk of harm from antibiotics, minimally until there is at least one effective commercial treatment widely available.” Although the project’s white paper includes includes terms and conditions designed to shield the authors from liability, RaDVaC’s self-experimentation raises important legal and ethical questions. Self-experimentation has a where to buy generic zithromax fascinating history. In the early 1900s, Walter Reed conducted experiments in Cuba deliberately exposing individuals to yellow fever that included members of the study team as participants.

These led to significant public health benefits in confirming that yellow fever was transmitted by mosquitoes, but also resulted in the deaths of several participants. Some Nobel Prize–winning work where to buy generic zithromax by scientists was based on self-experimentation that initially was seen as crazy. For instance, in 1984, Barry Marshall swallowed bacteria to prove that they caused gastritis and peptic ulcers. Many cardiac procedures are based on a 1929 experiment by a German doctor who inserted a catheter into his own heart.

Perhaps where to buy generic zithromax surprisingly, self-experimentation was once considered an ethical safeguard. The Nuremberg Code, established in response to grossly unethical experiments during World War II, permitted higher risk research if investigators also volunteered to participate, as they had in the earlier yellow fever studies. However, the idea that self-experimentation can justify higher research risks was abandoned in later codes of ethics. Not only is self-experimentation legally and ethically complex, but protections like independent review and informed consent, which are now required by where to buy generic zithromax research regulations, may be a better way to protect research participants.

Existing regulations for research were not designed to address self-experimentation. Laws governing research typically define research as an activity designed to produce generalizable knowledge, which does not cover experimentation that is badly designed, unlikely to produce useful data, and merely aiming to protect a small group of people. In addition, where to buy generic zithromax the U.S. Common Rule governs federally funded research, and RaDVaC is not using any federal funding.

However, Harvard is covered by a “federalwide assurance” under which the institution has agreed that all research it conducts will abide by the regulations (regardless of funding source). If studies where to buy generic zithromax of immune responses involving self-experimentation are planned in George Church’s laboratory at Harvard, as has been reported, this undoubtedly requires approval by an Institutional Review Board, which would provide some oversight of this self-experimentation. If results are to be published in a peer-reviewed journal, moreover, most, if not all, journals would require assurance of regulatory review and oversight. The U.S.

Food and Drug Administration has similar power where to buy generic zithromax to regulate research, and, perhaps more relevant for our purposes, “drugs” (including human biological materials and biologics)—even if they are not distributed for profit. The RaDVaC project uses biological materials—more specifically, small chains of amino acids from key antibiotics proteins—and therefore may fall under the FDA’s jurisdiction. While the FDA has not traditionally exercised this authority to regulate the analogous practice of small scale, do-it-yourself biohacking, it retains the power to do so in the future. Finally, if people were harmed where to buy generic zithromax by taking this treatment, they could also sue RaDVaC, but the disclaimers in the white paper are carefully designed to avoid liability.

Even if the law doesn’t adequately address this behavior, it may be ethically problematic—including because it could be a waste of scientific expertise and research effort. If RaDVaC intends to produce generalizable knowledge about this treatment, unsystematic self-experimentation is unlikely to produce useful information. For example, self-experimentation can lead to where to buy generic zithromax biased results if researchers overestimate the chance that the treatment works, or fail to report side effects. Randomized controlled trials, by contrast, are typically designed with researchers being blinded to who receives the intervention or the placebo.

Beyond self-experimentation, friends, staff members, and family members of the scientists involved are taking this treatment based on these expert’s recommendations, which could lead to two potential misconceptions. First, people where to buy generic zithromax taking the treatment might overestimate the likelihood that they are protected from antibiotics and change their behavior. If some individuals falsely believe they are protected, they might engage in riskier behavior that could cause harm to themselves and others. A second misconception is the idea that this is research that could benefit others.

The same data analyst seemed to believe this when he added “my continued existence through this zithromax will be a useful data set.” Yet the RaDVaC project could not produce useful where to buy generic zithromax data in the same way as standard, well-designed treatment trials, for example, because it is unclear whether individuals receiving the treatment are thoroughly evaluated or monitored, and there does not appear to be a control group. Even if everyone involved with this project fully understands what they are getting into, however, there are also questions about expertise and privilege. Senior scientists benefit where to buy generic zithromax from many layers of privilege. Investment in their education, expertise in specialized areas, and access to information or materials.

Arguably, these privileges come with a responsibility to use expertise for the benefit of society. If the RaDVaC treatment is potentially beneficial, then it is tragic not to test it in a where to buy generic zithromax rigorously designed study. Indeed, uncontrolled self-experimentation is part of a larger problem in the buy antibiotics zithromax. Panic about the zithromax has led to the widespread use of interventions outside of well-designed clinical trials.

Without such trials, we remain in the dark about which interventions offer net benefits or where to buy generic zithromax net harms. Insofar as the scientists involved have expertise in treatment research, they should either reform the RaDVaC project or lend their expertise to serious projects. On the other hand, if scientists don’t have relevant expertise, their overconfidence at their ability to work outside of their wheelhouse may be harmful. Earlier this where to buy generic zithromax week, Steven Salzberg, a computational biologist, called for experimental buy antibiotics treatments to be rolled out before the results of phase III testing.

An op-ed denouncing his misinformed view was published the next day, and Salzberg reversed his position immediately. Similarly, some of the named members of the RaDVaC project have expertise in genetics, neuroscience, and anti-aging research. Their time might be better spent on projects in where to buy generic zithromax these fields, which will still be important when this zithromax is finally over. Rather than trying everything but the kitchen sink against buy antibiotics, it would be wiser to focus our collective efforts on prioritizing the most promising interventions and testing them in rigorous research, as has been done for some treatments for buy antibiotics.

RaDVaC’s scientists should be encouraged to collaborate on systematic buy antibiotics treatment testing if they have relevant expertise, and to do other valuable things with their time if not.Not far from the famously multihued architecture of Bilbao in northern Spain, an underground world boasts its own vibrant display of color. The stalagmites and stalactites where to buy generic zithromax of Goikoetxe Cave are not just the usual white. Many range from honey to deep red. New research shows that these formations, known generally as speleothems, get their red color from organic compounds leached from soil and transported by water.

Scientists suggest, in an article published online in April in Quaternary International, that Goikoetxe where to buy generic zithromax Cave's speleothems record environmental conditions such as rainfall.The wildfire season is off to a roaring start. The hot summer is worsening drought and drying out vegetation—an unfortunately ideal environment for wildfires to rage. But that’s just one consequence of global warming. It’s also where to buy generic zithromax leading to flooding, torrential rainstorms and heat-related deaths.

In fact, the climate crisis has led to a widespread public health crisis. And as an ear, nose and throat physician, I see the effects more and more often. I vividly remember a patient who came in late for where to buy generic zithromax her appointment during a July heat wave. When I walked in, she said, “I’m so sorry I’m late, I was up all night walking my grandbaby around the train station.” Without air conditioning at home, the child was sweating through her clothes in the heat of the night, putting her at risk for dehydration.

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Start Preamble Buy levitra online with prescription U.S zithromax for ear . Small Business Administration. Interim final zithromax for ear rule. This interim final rule announces the implementation of section 311 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act (the Economic Aid Act). The Economic Aid Act authorizes the U.S.

Small Business Administration to guarantee additional loans under the temporary Paycheck Protection Program, which was originally established under the antibiotics Aid, Relief, and Economic Security Act to provide economic relief to small businesses nationwide adversely impacted zithromax for ear under the antibiotics Disease 2019 (buy antibiotics) Emergency Declaration (buy antibiotics Emergency Declaration) issued by President Trump on March 13, 2020. Section 311 of the Economic Aid Act adds a second temporary program to SBA's 7(a) Loan Program titled, “Paycheck Protection Program Second Draw Loans.” This interim final rule implements the key provisions of section 311 of the Economic Aid Act and requests public comment. Effective Date. This interim final rule is effective January 12, zithromax for ear 2021. Applicability Date.

This interim final rule applies to loan applications and applications for loan forgiveness submitted for Paycheck Protection Program Second Draw Loans. Comment Date zithromax for ear . Comments must be received on or before February 16, 2021. You may submit comments, identified by number SBA-2021-0002 through the Federal eRulemaking Portal. Http://www.regulations.gov.

Follow the instructions for submitting comments. SBA will post all comments on www.regulations.gov. If you wish to submit confidential business information (CBI) as defined in the User Notice at www.regulations.gov, please send an email to ppp-ifr@sba.gov. All other comments must be submitted through the Federal eRulemaking Portal described above. Highlight the information that you consider to be CBI and explain why you believe SBA should hold this information as confidential.

SBA will review the information and make the final determination whether it will publish the information. Start Further Info Call Center Representative at 833-572-0502, or the local SBA Field Office. The list of offices can be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices. End Further Info End Preamble Start Supplemental Information I. Background Information On December 27, 2020, President Trump signed the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act (the Economic Aid Act) (Pub.

L. 116-260) into law to provide continued assistance to individuals and businesses that have been financially impacted by the ongoing antibiotics zithromax. Section 311 of the Economic Aid Act added a new temporary section 7(a)(37) to the Small Business Act (15 U.S.C. 636(a)(37)). This new section authorizes the U.S.

Small Business Administration (SBA or the Administration) to guarantee Paycheck Protection Program Second Draw Loans (PPP Second Draw Program), under generally the same terms and conditions available under the Paycheck Protection Program (PPP) established under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)). Under section 311, SBA may guarantee loans under the PPP Second Draw Program through March 31, 2021 (“Second Draw PPP Loans”) to borrowers that previously received a PPP loan under section 7(a)(36) of the Small Business Act (“First Draw PPP Loans”) and have used or will use the full amount of the initial PPP loan for authorized purposes on or before the expected date of disbursement of the Second Draw PPP Loan. Like First Draw PPP Loans, Second Draw PPP Loans are intended to provide expeditious relief to America's small Start Printed Page 3713businesses. Second Draw PPP Loans generally are guaranteed by SBA under the same terms, conditions, and processes as First Draw PPP Loans.

SBA guarantees 100 percent of Second Draw PPP Loans and SBA may forgive up to the full principal loan amount. Second Draw PPP Loans are subject to SBA's and the Department of the Treasury's (Treasury's) consolidated interim final rules implementing updates to the Paycheck Protection Program for First Draw PPP Loans (“Consolidated First Draw PPP IFR”) issued concurrently with this interim final rule (IFR) [] and all PPP loan program requirements, except as specified in this IFR. The key differences between First Draw PPP Loans and Second Draw PPP Loans are described in this IFR, which explains the loan terms, eligibility requirements, and application process for Second Draw PPP Loans. II. Comments and Immediate Effective Date This interim final rule is being issued without advance notice and public comment because section 303 of the Economic Aid Act authorizes SBA to issue regulations to implement the Economic Aid Act without regard to notice requirements.

In addition, this rule is being issued to allow for immediate implementation of this program. The intent of the Economic Aid Act is that SBA provide relief to America's small businesses expeditiously. The last day to apply for and receive a PPP loan is March 31, 2021. Given the short duration of this program, and the urgent need to issue loans quickly, the Administrator in consultation with the Secretary has determined that it is impractical and not in the public interest to provide a 30-day delayed effective date. An immediate effective date will give small businesses the maximum amount of time to apply for loans and lenders the maximum amount of time to process applications before the program ends.

This good cause justification also supports waiver of the 60-day delayed effective date for major rules under the Congressional Review Act at 5 U.S.C. 808(2). Although this IFR is effective immediately, comments are solicited from interested members of the public on all aspects of the interim final rule. These comments must be submitted on or before February 16, 2021. SBA will consider these comments and the need for making any revisions as a result of these comments.

III. Summary of Key Terms of PPP Second Draw Loans The rules applicable to Second Draw PPP Loans are published in section IV of this IFR. This summary provides additional information and explains the key terms in the IFR. All references to subsections refer to section IV. Second Draw PPP Loans are generally subject to the same terms, conditions and requirements as First Draw PPP Loans.

These include, but are not limited to the following terms. The guarantee percentage is 100 percent. No collateral will be required. No personal guarantees will be required. The interest rate will be 100 basis points or one percent, calculated on a non-compounding, non-adjustable basis.[] The maturity is five years.

All loans will be processed by all lenders under delegated authority and lenders will be permitted to rely on certifications of the borrower to determine the borrower's eligibility and use of loan proceeds. Subsection (b) of this IFR confirms that these terms apply to Second Draw PPP Loans. Subsection (b) also confirms that SBA's Consolidated First Draw PPP IFR, Frequently Asked Questions (FAQs), and other guidance about PPP loans under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) apply to Second Draw PPP Loans, except as specified in this IFR.[] The Economic Aid Act includes terms and conditions, including but not limited to terms relating to eligibility and a borrower's maximum loan amount, that apply only to Second Draw PPP Loans and do not apply to First Draw PPP Loans, regardless of when the First Draw PPP Loan is made. These terms and conditions specific to Second Draw PPP Loans are summarized below.

A. Eligibility Requirements 1. General Eligibility Requirements In general, the Economic Aid Act made the eligibility requirements for Second Draw PPP Loans narrower than the eligibility requirements for First Draw PPP Loans. The Economic Aid Act generally provides that a borrower is eligible for a Second Draw PPP Loan only if it has 300 or fewer employees and experienced a revenue reduction in 2020 relative to 2019 (described further below).[] In addition, the Economic Aid Act provides that a Second Draw PPP Loan may only be made to an eligible borrower that (i) has received a First Draw PPP Loan, and (ii) has used, or will use, the full amount of the First Draw PPP Loan on or before the expected date on which the Second Draw PPP Loan is disbursed to the borrower.[] Accordingly, subsections (c)(1)(i) through (c)(1)(iv) of this IFR implement these criteria. Subsection (c)(1)(ii) of the IFR clarifies that “the full amount” of the borrower's First Draw PPP Loan includes the amount of any increase on such First Draw PPP Loan made pursuant to the Economic Aid Act.

In addition, subsection (c)(1)(ii) of the IFR clarifies that the borrower must have spent the full amount of its First Draw PPP Loan on eligible expenses under the PPP rules to be eligible for a Second Draw PPP Loan. This clarification will help ensure program integrity by preventing a borrower from receiving a Second Draw PPP Loan if the borrower has not complied with PPP loan program requirements.[] 2. Revenue Reduction Requirement The Economic Aid Act provides that, to be eligible for a Second Draw PPP Loan, the borrower must have experienced a revenue reduction of 25% or greater in 2020 relative to 2019.[] A borrower must calculate this revenue reduction by comparing the borrower's quarterly gross receipts for one quarter in 2020 with the borrower's gross receipts for the corresponding quarter of 2019. For example, a borrower with gross receipts of $50,000 in the second quarter of 2019 and gross receipts of $30,000 in the second quarter of 2020 has experienced a revenue reduction of 40 percent between the quarters, and is therefore eligible for a Second Draw PPP loan (assuming all other eligibility criteria are met). Subsection (c)(1)(iv)(A) of the IFR reflects this methodology.

Subsection (c)(1)(iv)(B) of the IFR provides that a borrower that was in operation in all four quarters of 2019 is deemed to have experienced the required revenue reduction if it Start Printed Page 3714experienced a reduction in annual receipts of 25 percent or greater in 2020 compared to 2019 and the borrower submits copies of its annual tax forms substantiating the revenue decline. This provision will allow a borrower to provide annual tax return forms to substantiate its revenue reduction. The Administrator, in consultation with the Secretary of the Treasury (Secretary), has determined that this is necessary to improve administrability of Second Draw PPP Loans by providing borrowers an additional verifiable method for substantiating their revenue reduction. This method will be particularly important for small borrowers that may not have quarterly revenue information readily available. Moreover, this approach is appropriate because, if annual filings show a 25 percent revenue reduction, then at least one quarter in 2020 would have had at least a 25 percent revenue reduction.

A borrower that did not experience a 25 percent annual decline in revenues, or that was not in operation in all four quarters of 2019, may still meet the revenue reduction requirement under one of the quarterly measurements described above. The Economic Aid Act does not include a general definition of gross receipts for purposes of determining a borrower's revenue reduction.[] Subsection (c)(2) of the IFR defines gross receipts consistent with the definition of receipts in 13 CFR 121.104 of SBA's size regulations because this definition appropriately captures the type of income that is typically included in a small business's gross receipts.[] Moreover, this definition will enhance the administrability of Second Draw PPP Loans because it is a definition already used by the Administration and many small businesses. The IFR specifies that any forgiveness amount of a First Draw PPP Loan that a borrower received in calendar year 2020 is excluded from a borrower's gross receipts. Excluding the forgiveness amount from a borrower's gross receipts is consistent with section 7A(i) of the Small Business Act, which expressly excludes PPP forgiveness amounts from being taxed as income.[] This clarification ensures the effectiveness of the second draw loan program by ensuring that a borrower is not disqualified from receiving a Second Draw PPP Loan because it received forgiveness on a First Draw PPP Loan. This furthers the purpose of the second draw loan provisions, which is to deliver additional aid to small businesses that previously received a First Draw PPP Loan.

3. Business Concerns With More Than One Physical Location Under the CARES Act, any single business entity that is assigned a NAICS code beginning with 72 (including hotels and restaurants) and employs not more than 500 employees per physical location is eligible to receive a First Draw PPP Loan.[] In addition, as discussed below, under the Consolidated First Draw PPP IFR, SBA's affiliation rules (13 CFR 121.301) do not apply to any business entity that is assigned a NAICS code beginning with 72 and that employs not more than a total of 500 employees.[] As a result, if each hotel or restaurant location owned by a parent business is a separate legal business entity and employs not more than 500 employees, each hotel or restaurant location is permitted to apply for a separate PPP loan provided it uses its unique EIN. Section 317 of the Economic Aid Act modified this provision for Second Draw PPP Loans by reducing the limit on employees per physical location to 300. Accordingly, a single business entity that is assigned a NAICS code beginning with 72 is eligible to receive a Second Draw PPP Loan if it employs no more than 300 employees per physical location and meets the revenue reduction requirements and otherwise satisfies the eligibility criteria described in this IFR.[] Under section 317 of the Economic Aid Act, the same standard applies to certain news organizations.[] Subsections (c)(3) and (c)(4) of the IFR implement these statutory provisions. Borrowers may consult PPP Frequently Asked Question (FAQ) 24 [] for guidance on these standards for business concerns with more than one physical location, except that, for Second Draw PPP Loans, the number of employees per physical location is limited to 300 rather than 500.

B. Affiliation Rules The same affiliation rules that apply to First Draw PPP Loans apply to Second Draw PPP Loans, except as provided in this IFR. As with First Draw PPP Loans, in most cases, a borrower is considered together with its affiliates to determine eligibility for the PPP.[] However, the CARES Act waived the affiliation rules for certain categories of borrowers.[] Paragraph 7(a)(37)(E) of the Small Business Act, as amended by the Economic Aid Act, applies the same Start Printed Page 3715waivers to Second Draw PPP Loans, adds a waiver for certain eligible news organizations, and makes adjustments to reflect the reduced size requirement for Second Draw PPP Loans. Specifically, business concerns with a NAICS code beginning with 72 qualify for the affiliation waiver for Second Draw PPP Loans if they employ 300 or fewer employees. Eligible news organizations with a NAICS code beginning with 511110 or 5151 (or majority-owned or controlled by a business concern with those NAICS codes) may qualify for the affiliation waiver for Second Draw PPP Loans only if they employ 300 or fewer employees per physical location.[] Subsection (d)(2) implements these revised affiliation waivers.

SBA also adopted a religious exemption to the affiliation rules by regulation,[] which applies to Second Draw PPP loans. C. Excluded Entities An entity that is ineligible to receive a First Draw PPP Loan under the CARES Act or Consolidated First Draw PPP IFR is also ineligible for a Second Draw PPP Loan.[] Subsection (e)(1) of the IFR implements this restriction. Subsection (e)(1) ensures that a borrower that received a First Draw PPP Loan despite being ineligible to receive the loan is not eligible to receive a Second Draw PPP Loan. The Economic Aid Act also prohibits several additional categories of borrowers from receiving a Second Draw PPP Loan under section 7(a)(37) of the Small Business Act.

These categories of prohibited borrowers are listed in subsection (e) of the IFR. A business concern or entity primarily engaged in political activities or lobbying activities, including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or that describes itself as a think tank in any public documents; [] certain entities organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or with other specified ties to the People's Republic of China or the Special Administrative Region of Hong Kong; [] any person required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C. 612); [] a person or entity that receives a grant for shuttered venue operators under section 324 of the Economic Aid Act; [] entities in which the President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person owns, controls, or holds at least 20 percent of any class of equity; [] or a publicly traded company, defined as an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the Securities Exchange Act of 1934 (15 U.S.C. 78f).[] In addition, subsection (e)(9) of this IFR provides that an entity that has previously received a Second Draw PPP Loan may not receive another Second Draw PPP Loan, as required by the Economic Aid Act.[] Subsection (e)(9) also prohibits an entity that has permanently closed from receiving a Second Draw PPP Loan because paragraph 7(a)(37)(A)(iv) of the Small Business Act is best understood to describe existing businesses. The Administrator, in consultation with the Secretary, has determined this provision is also necessary to maintain program integrity, prevent abuse, and preserve the availability of Second Draw PPP Loan funds for businesses still in operation.

Preserving funds for such businesses is necessary because only businesses that are still in operation will retain employees, which is a primary purpose of the PPP. A borrower that has temporarily closed or temporarily suspended its business remains eligible for a Second Draw PPP Loan. D. Payroll Cost Calculation In general, section 307 of the Economic Aid Act provides that the maximum loan amount for a Second Draw PPP Loan is equal to the lesser of two and half months of the borrower's average monthly payroll costs or $2 million. Relative to First Draw PPP loans, the Economic Aid Act adjusted the methodology for calculating a borrower's payroll costs.

Unlike First Draw PPP Loans, the Economic Aid Act provides that the relevant time period for calculating a borrower's payroll costs for a Second Draw PPP Loan is either the twelve-month period prior to when the loan is made or calendar year 2019. The Act also provided tailored methodologies for certain categories of borrowers. These calculations are reflected in subsection (f) of this IFR. Subsection (f) of the IFR uses “calendar year 2020” to refer to “the twelve-month period prior to when the loan is made.” Calculating payroll costs based on calendar year 2020 rather than the twelve months preceding the date the loan is made will simplify the calculations and documentation requirements for borrowers because payroll records are more commonly created and retained on a calendar-year basis. Allowing borrowers to calculate payroll costs based on calendar year 2020 is also not expected to result in a significant difference in payroll costs compared to the twelve months preceding the date the loan is made because all Second Draw PPP Loans will be made in the first quarter of 2021.

However, the rule notes that Second Draw PPP Loan borrowers who are not self-employed (including sole proprietorships and independent contractors) are also permitted to use the precise 1-year period before the date on which the loan is made to calculate payroll costs if they choose not to use 2019 or 2020 to calculate payroll costs. Consistent with the Economic Aid Act, subsections (f)(3) and (f)(4) of the IFR include tailored calculation methodologies for seasonal businesses, new entities that did not exist for the full twelve-month period preceding the Second Draw PPP Loan, and borrowers assigned a NAICS code beginning with 72 at the time of disbursement. For borrowers assigned a NAICS code beginning with 72 at the time of disbursement, the Economic Aid Act provides that the maximum loan amount is equal to three-and-a-half (3.5) months of payroll costs rather than two-and-a-half (2.5) months.[] These subsections also provide that, for a borrower with a NAICS code beginning with 72 that would fall into more than one category listed in subsection (f) (for example, a business with a NAICS code beginning with 72 that is also a seasonal business or is also a new entity without 12 months of payroll costs), the borrower may calculate its average monthly payroll costs based on the methodology that applies to the entity but may use the 3.5 multiplier Start Printed Page 3716applicable to businesses with a NAICS code beginning with 72. The Administrator, in consultation with the Secretary, has determined that this methodology is necessary to provide small businesses in the accommodation and food services sector the full amount of relief provided in the Economic Aid Act while allowing these borrowers to calculate their average monthly payroll costs accurately. The Economic Aid Act included a new payroll cost calculation for farmers and ranchers receiving First Draw PPP Loans.

However, it did not specify how payroll costs should be calculated for Second Draw PPP Loans to farmers and ranchers. This IFR clarifies that the same general calculation for farmers and ranchers applicable to First Draw PPP Loans applies to Second Draw PPP Loans, with adjustments that (i) eliminate the provision for refinancing of an Economic Injury Disaster Loan (EIDL), which does not apply to Second Draw PPP Loans, and (ii) apply the choice of time period for calculating a farmer's or rancher's payroll costs for Second Draw PPP Loans, consistent with other Second Draw PPP Loans. This IFR also specifies that, in calculating a farmer's or rancher's maximum loan amount, any employee payroll costs should be subtracted from the farmer's or rancher's gross income to avoid double-counting amounts that represent pay to the employees of the farmer or rancher. Subsections (f)(7) and (f)(8) of the IFR include tailored calculation methodologies for self-employed individuals and partnerships. These methodologies are based on the corresponding methodologies for self-employed individuals and partnerships that are used for First Draw PPP Loans.[] These methodologies have been adjusted to eliminate the provision for refinancing of an EIDL loan, which does not apply to Second Draw PPP loans and to apply the choice of time period for calculating payroll costs, consistent with other Second Draw PPP loans.

Finally, subsection (f)(9) provides that businesses that are part of a single corporate group shall in no event receive more than $4,000,000 of Second Draw PPP Loans in the aggregate. The Administrator, in consultation with the Secretary, determined that limiting the amount of Second Draw PPP Loans that a single corporate group may receive will promote the availability of PPP loans to the largest possible number of borrowers, consistent with the CARES and Economic Aid Act. The Administrator has concluded that a limitation of $4,000,000 is appropriate because it is proportional to the $20,000,000 maximum amount for corporate groups that is provided under the Consolidated First Draw PPP IFR when the maximum loan amount for a single PPP loan is $10,000,000. E. Second Draw PPP Loan Application and Documentation Requirements Subsection (g) of this IFR includes the application and documentation requirements for Second Draw PPP Loans.

The documentation required to substantiate an applicant's payroll cost calculations is generally the same as documentation required for First Draw PPP Loans. However, no additional documentation to substantiate payroll costs will be required if the applicant (i) used calendar year 2019 figures to determine its First Draw PPP Loan amount, (ii) used calendar year 2019 figures to determine its Second Draw PPP Loan amount (instead of calendar year 2020), and (iii) the lender for the applicant's Second Draw PPP Loan is the same as the lender that made the applicant's First Draw PPP Loan. In such cases, additional documentation is not required because the lender already has the relevant documentation supporting the borrower's payroll costs. The lender may request additional documentation, however, if on further review the lender concludes that it would be useful in conducting the lender's good-faith review of the borrower's loan amount calculation. For loans with a principal amount greater than $150,000, the applicant must also submit documentation adequate to establish that the applicant experienced a revenue reduction of 25% or greater in 2020 relative to 2019.

(The revenue reduction requirement is addressed in subsection (c)(1)(iv) of this IFR.) Such documentation may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, quarterly financial statements or bank statements. For loans with a principal amount of $150,000 or less, such documentation is not required at the time the borrower submits its application for a loan, but must be submitted on or before the date the borrower applies for loan forgiveness, as required under the Economic Aid Act.[] If a borrower does not submit an application for loan forgiveness, such documentation must be provided upon SBA's request. F. Lender Requirements Subsection (g) of this IFR contains the provisions specific to lenders for Second Draw PPP Loans. Paragraph 7(a)(37)(K) of the Small Business Act, added by the Economic Aid Act, states that a lender approved to make First Draw PPP loans may make Second Draw PPP Loans under the same terms and conditions as new First Draw PPP Loans.

Subsection (g)(2) of this IFR provides that lenders are subject to the same requirements when making Second Draw PPP Loans as when they are making First Draw PPP Loans. These provisions allow a lender approved to make Second Draw PPP Loans to use existing program guidance and standard operating procedures to the maximum extent practicable.[] The requirements applicable to PPP lenders are in sections (C) and (D) of the Consolidated First Draw PPP IFR. If a borrower has not submitted new payroll documentation with its Second Draw PPP Loan application because it previously submitted 2019 payroll information to the same lender when it applied for its First Draw PPP Loan, then the lender must confirm the borrower's average monthly payroll costs based on that prior documentation. In addition, for a Second Draw PPP Loan greater than $150,000, the lender must confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction. If the lender identifies errors in the borrower's calculation or a material lack of substantiation in the borrower's supporting documents, the lender should work with the borrower to remedy the issue.

G. Loans to Borrowers With Unresolved First Draw PPP Loans As described in SBA's interim final rule on SBA Loan Review Procedures and Related Borrower and Lender Responsibilities, SBA may review any PPP loan, as the Administrator deems appropriate.[] Subsection (i) of the IFR establishes procedures relating to the handling of a Second Draw PPP Loan application by a borrower whose First Draw PPP Loan is under review by SBA (“unresolved borrower”). If a borrower's First Draw PPP loan is under review by SBA and/or information in SBA's possession indicates that the borrower may have been ineligible for the First Start Printed Page 3717Draw PPP Loan it received or for the loan amount it received, the lender will receive notification from SBA when the lender submits an application for a guaranty of a Second Draw PPP Loan and will not receive an SBA loan number until the issue related to the unresolved borrower's First Draw PPP Loan is resolved. SBA will resolve issues related to unresolved borrowers expeditiously. These procedures are designed to promote compliance with the eligibility requirements for Second Draw PPP Loans by preventing additional loans from being made to borrowers that were not eligible for a First Draw PPP Loan or received an impermissible loan amount.

At the same time, these procedures do not disqualify an eligible unresolved borrower from receiving a Second Draw PPP Loan, in recognition that many flags will be resolved in the borrower's favor. The Administrator, in consultation with the Secretary, has determined that these procedures strike an appropriate balance between promoting program integrity and preventing abuse, while making Second Draw PPP Loans available to all eligible borrowers as expeditiously as possible. SBA will set aside available appropriations to fund Second Draw PPP Loans applied for by unresolved borrowers in the event they are approved. H. Loan Forgiveness Loan forgiveness of Second Draw PPP Loans and the loan review process for Second Draw PPP Loans are generally subject to the interim final rules regarding Loan Forgiveness and SBA Loan Review Procedures and Related Borrower and Lender Responsibilities, as modified to conform to the Economic Aid Act by the Consolidated First Draw PPP IFR, which is being published concurrently with this IFR.

Subsection (j) contains forgiveness provisions specific to Second Draw PPP loans. Table of Contents (a) Second Draw PPP Loan Program (b) What requirements apply to Second Draw PPP Loans?. (c) Who is eligible for a Second Draw PPP Loan?. (d) How do SBA's affiliation rules affect an applicant's eligibility for a Second Draw PPP Loan?. (e) Who is not eligible for a Second Draw PPP Loan?.

(f) What is the maximum loan amount for a Second Draw PPP Loan?. (g) How do I submit an application for a Second Draw PPP Loan and what documentation must I provide to demonstrate eligibility?. (h) What do lenders need to know and do?. (i) Will an applicant's Second Draw PPP Loan application be affected if there are unresolved issues regarding the applicant's First Draw PPP Loan?. (j) Are Second Draw PPP Loans eligible for loan forgiveness?.

IV. Paycheck Protection Program Second Draw Loans (a) Second Draw PPP Loan Program Under section 7(a)(37) of the Small Business Act (15 U.S.C. 636(a)(37)), SBA is authorized to guarantee Paycheck Protection Program Second Draw Loans (“Second Draw PPP Loans”). (b) What requirements apply to Second Draw PPP Loans?. (1) Second Draw PPP Loans are subject to SBA's and the Department of the Treasury's (“Treasury's”) consolidated interim final rule implementing the Paycheck Protection Program (“Consolidated First Draw PPP IFR”) and all PPP loan program requirements, except as otherwise provided in this section, including but not limited to the following terms.

(i) The guarantee percentage is 100 percent. (ii) No collateral will be required. (iii) No personal guarantees will be required. (iv) The interest rate will be 100 basis points or one percent, calculated on a non-compounding, non-adjustable basis. (v) The maturity is five years.

(vi) All loans will be processed by all lenders under delegated authority and lenders will be permitted to rely on certifications of the borrower in order to determine eligibility of the borrower and the use of loan proceeds. (2) Frequently Asked Questions and other guidance issued by SBA or by SBA in consultation with the Department of the Treasury with respect to PPP loans under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) (“First Draw PPP Loans”) apply to Second Draw PPP Loans, except as otherwise provided in this section. (c) Who is eligible for a Second Draw PPP Loan?. Subject to subsection (e) of this section, below, the following applicants are eligible for Second Draw PPP Loans.

(1) An applicant is eligible for a Second Draw PPP Loan if it is a business concern, independent contractor, eligible self-employed individual, sole proprietor, nonprofit organization eligible for a First Draw PPP Loan, veterans organization, Tribal business concern, housing cooperative, small agricultural cooperative, eligible 501(c)(6) organization or destination marketing organization, or an eligible nonprofit news organization [] that. (i) Previously received a First Draw PPP loan in accordance with the eligibility criteria in the Consolidated First Draw PPP IFR. (ii) has used, or will use, the full amount of its First Draw PPP Loan (including the amount of any increase on such First Draw PPP Loan) on authorized uses under subsection (B)(11) of the Consolidated First Draw PPP IFR on or before the expected date on which the Second Draw PPP Loan will be disbursed; [] (iii) employs not more than 300 employees, unless it satisfies the alternative criteria for businesses with a North American Industry Classification System (“NAICS”) code beginning with 72 and eligible news organizations with more than one physical location described in subsection (c)(3) or (c)(4) of this section. And (iv) (A) experienced a reduction in revenue in calendar year 2020, measured as follows. (1) the applicant had gross receipts during the first, second, third, or fourth quarter in 2020 that demonstrate at least a 25 percent reduction from the applicant's gross receipts during the same quarter in 2019 (for example, an applicant that had gross receipts of $50,000 in the second quarter of 2019 and had gross receipts of $30,000 in the second quarter of 2020 experienced a 40 percent revenue reduction between these two quarters).

(2) if the applicant was not in business during the first or second quarter of 2019, but was in business during the third and fourth quarters of 2019, the applicant had gross receipts during the first, second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the applicant's gross receipts during the third or fourth quarter of 2019 (for example, an applicant that had gross receipts of $50,000 in the third quarter of 2019 and had gross receipts of $30,000 in the third quarter of 2020-demonstrating a reduction of 40 percent from the applicant's gross receipts during the third quarter in 2019). (3) if the applicant was not in business during the first, second, or third quarter of 2019, but was in business during the fourth quarter of 2019, the applicant had gross receipts Start Printed Page 3718during the first, second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the fourth quarter of 2019 (for example, an applicant that had gross receipts of $50,000 in the fourth quarter of 2019 and had gross receipts of $30,000 in the fourth quarter of 2020-demonstrating a reduction of 40 percent from the applicant's gross receipts during the fourth quarter in 2019). Or (4) if the applicant was not in business during 2019, but was in operation on February 15, 2020, the applicant had gross receipts during the second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the gross receipts of the entity during the first quarter of 2020 (for example, an applicant that had gross receipts of $50,000 in the first quarter of 2020 and had gross receipts of $30,000 in the fourth quarter of 2020—demonstrating a reduction of 40 percent from the applicant's gross receipts during the first quarter in 2020). (B) An applicant that was in operation in all four quarters of 2019 is deemed to have experienced the revenue reduction in subsection (c)(1)(iv)(A)(1) if it experienced a reduction in annual receipts of 25 percent or greater in 2020 compared to 2019 and the borrower submits copies of its annual tax forms substantiating the revenue decline. (2)(i) Gross receipts includes all revenue in whatever form received or accrued (in accordance with the entity's accounting method) from whatever source, including from the sales of products or services, interest, dividends, rents, royalties, fees, or commissions, reduced by returns and allowances.

Generally, receipts are considered “total income” (or in the case of a sole proprietorship, independent contractor, or self-employed individual “gross income”) plus “cost of goods sold,” and excludes net capital gains or losses as these terms are defined and reported on IRS tax return forms. Gross receipts do not include the following. Taxes collected for and remitted to a taxing authority if included in gross or total income (such as sales or other taxes collected from customers and excluding taxes levied on the concern or its employees). Proceeds from transactions between a concern and its domestic or foreign affiliates. And amounts collected for another by a travel agent, real estate agent, advertising agent, conference management service provider, freight forwarder or customs broker.

All other items, such as subcontractor costs, reimbursements for purchases a contractor makes at a customer's request, investment income, and employee-based costs such as payroll taxes, may not be excluded from gross receipts. (ii) Gross receipts of affiliates are calculated as follows. (A) Gross receipts of a borrower with affiliates is calculated by adding the gross receipts of the business concern with the gross receipts of each affiliate. (B) If a borrower has acquired an affiliate or been acquired as an affiliate during 2020, gross receipts includes the receipts of the acquired or acquiring concern. This aggregation applies for the entire period of measurement, not just the period after the affiliation arose.

However, if a concern acquired a segregable division of another business concern during 2020, gross receipts do not include the receipts of the acquired division prior to the acquisition. (C) The gross receipts of a former affiliate are not included. This exclusion of gross receipts of such former affiliate applies during the entire period of measurement, rather than only for the period after which affiliation ceased. However, if a borrower sold a segregable division during 2020, the gross receipts will continue to include the receipts of the division that was sold. (D) All terms in this subsection shall have the meaning attributed to them by the IRS.

(iii) For an eligible nonprofit organization, a veterans organization, an eligible nonprofit news organization, an eligible 501(c)(6) organization, or eligible destination marketing organization, gross receipts means gross receipts within the meaning of section 6033 of the Internal Revenue Code of 1986. (iv) The amount of any forgiven First Draw PPP Loan shall not be included toward any borrower's gross receipts. (3) Any business concern that has more than one physical location and that employs not more than 300 employees per physical location is eligible to receive a Second Draw PPP Loan if it is assigned a NAICS code beginning with 72 at the time of loan disbursement and otherwise meets the eligibility criteria in subsection (c)(1). (4) Any business concern, or any station which broadcasts pursuant to a license granted by the Federal Communications Commission under title III of the Communications Act of 1934 (47 U.S.C. 301 et seq.), that has more than one physical location and that employs not more than 300 employees per physical location is eligible to receive a Second Draw PPP Loan if it meets the eligibility criteria in subsection (c)(1) and.

(1) Is majority owned or controlled by a business concern that is assigned a NAICS code beginning with 511110 or 5151 or, with respect to a public broadcasting entity (as defined in section 397(11) of the Communications Act of 1934 (47 U.S.C. 397(11))), has a trade or business that falls under such a code. And (2) makes a good faith certification that proceeds of the loan will be used to support expenses at the component of the organization that produces or distributes locally focused or emergency information. (d) How do SBA's affiliation rules affect an applicant's eligibility for a Second Draw PPP Loan?. (1) Eligibility for Second Draw PPP Loans is governed by the same affiliations rules (and waivers) as First Draw PPP Loans, except as described in subsection (d)(2).

(2) The affiliation rules under 13 CFR 121.301(f) are waived with respect to eligibility for a Second Draw PPP Loan for. (i) Any business concern with not more than 300 employees that, as of the date on which the covered loan is disbursed, is assigned a NAICS code beginning with 72. And (ii) (A) any business concern (including any station which broadcasts pursuant to a license granted by the Federal Communications Commission under title III of the Communications Act of 1934 (47 U.S.C. 301 et seq.) without regard for whether such a station is a concern as defined in 13 CFR 121.105, or any successor thereto) that employs not more than 300 employees, per physical location of such business concern and is majority owned or controlled by a business concern that is assigned a NAICS code beginning with 511110 or 5151. Or (B) any nonprofit organization that is assigned a NAICS code beginning with 5151.

(e) Who is not eligible for a Second Draw PPP Loan?. An applicant is not eligible for a Second Draw PPP Loan, even if it meets the eligibility requirements of subsection (c) of this section, if the applicant is. (1) Excluded from eligibility under the Consolidated First Draw PPP IFR; [] (2) a business concern or entity primarily engaged in political activities or lobbying activities, as defined in section 3 of the Lobbying Disclosure Act of 1995 (2 U.S.C. 1602), including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or Start Printed Page 3719otherwise describes itself as a think tank in any public documents. (3) any business concern or entity.

(i) For which an entity created in or organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or that has significant operations in the People's Republic of China or the Special Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership. Or (ii) that retains, as a member of the board of directors of the business concern, a person who is a resident of the People's Republic of China. (4) any person required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C. 612). (5) any person or entity that receives a grant for shuttered venue operators under section 324 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act.

(6) any entity in which the President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined under applicable common law, directly or indirectly holds a controlling interest in the entity, where. (i) “controlling interest” means owning, controlling, or holding not less than 20 percent, by vote or value, of the outstanding amount of any class of equity interest in an entity. (ii) “equity interest” means. (A) A share in an entity, without regard to whether the share is transferable or classified as stock or anything similar. (B) a capital or profit interest in a limited liability company or partnership.

Or (C) a warrant or right, other than a right to convert, to purchase, sell, or subscribe to a share or interest described in (A) or (B), respectively. (iii) “Executive department” has the meaning given the term in section 101 of title 5, United States Code. (iv) “Member of Congress” means a Member of the Senate or House of Representatives, a Delegate to the House of Representatives, and the Resident Commissioner from Puerto Rico. And (v) For the purpose of determining whether a person has a controlling interest in the entity, the securities owned, controlled, or held by the President, the Vice President, the head of an Executive department, or a Member of Congress, shall be aggregated with the securities held by his or her spouse as determined under applicable common law. (7) any issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the Securities Exchange Act of 1934 (15 U.S.C.

78f), where the terms “exchange,” “issuer,” and “security” have the meanings given those terms in section 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)) (except SBA will not consider whether a news organization that is eligible under subsection (c)(4) is affiliated with an entity, which includes any entity that owns or controls such news organization, that is an issuer). (8) an entity that has previously received a Second Draw PPP Loan. Or (9) an entity that has permanently closed. (f) What is the maximum loan amount for a Second Draw PPP Loan?.

(1) In general, the maximum loan amount for a Second Draw PPP Loan is equal to the lesser of two and half months of the borrower's average monthly payroll costs or $2 million, except as otherwise specified in this subsection (e). A borrower's average monthly payroll costs may be based on calendar year 2020, calendar year 2019,[] or as otherwise specified in subsections (f)(2) through (f)(9) of this section. €œPayroll costs” has the same meaning as in subsections (B)(4)(g) and (B)(4)(h) of the Consolidated First Draw PPP IFR and is calculated in the same manner. In calculating a borrower's payroll costs, the borrower must subtract any compensation paid to an employee in excess of $100,000 on an annualized basis, as prorated for the time period during which the payments are made or the obligation to make the payments is incurred. (2) Except as otherwise provided in subsection (f)(3) through (f)(7), the maximum amount of a Second Draw PPP Loan is calculated as the lesser of.

(i) The product obtained by multiplying. (A) The average total monthly payment for payroll costs incurred or paid by the borrower during 2019 or 2020 (at the election of the borrower). By (B) 2.5. Or (ii) $2,000,000. (3) The maximum amount of a Second Draw PPP Loan to a borrower that is a seasonal employer (meaning an employer that does not operate for more than 7 months in any calendar year or that during the preceding calendar year, had gross receipts for any 6 months of that year that were not more than 33.33 percent of the gross receipts of the employer for the other 6 months of that year) is calculated as the lesser of.

(i) The product obtained by multiplying. (A) At the election of the borrower, the average total monthly payments for payroll costs incurred or paid by the borrower for any 12-week period between February 15, 2019 and February 15, 2020. By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5). Or (ii) $2,000,000. (4) The maximum amount of a Second Draw PPP Loan to a borrower that did not exist during the 1-year period preceding February 15, 2020, but was in operation on February 15, 2020 (“new entity”), is calculated as the lesser of.

(i) The product obtained by multiplying. (A) The quotient obtained by dividing. (1) The sum of the total monthly payments by the borrower for payroll costs paid or incurred by the borrower as of the date on which the borrower applies for the Second Draw PPP Loan. By (2) the number of months in which those payroll costs were paid or incurred. By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5).

Or (ii) $2,000,000. (5) The maximum amount of a Second Draw PPP Loan made to a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10) (that is not a seasonal employer or new entity addressed in subsection (f)(3) or (f)(4) or a borrower with self-employment income or a partnership addressed in subsection (f)(7) or (f)(8) of this section) is calculated as the lesser of. (i) The product obtained by multiplying. (A) The average total monthly payment for payroll costs incurred or paid by the borrower during either 2019 or 2020 (at the borrower's election) by (B) 3.5. Or (ii) $2,000,000.

(6) (i) The maximum amount of a Second Draw PPP Loan to a farmer or rancher that:Start Printed Page 3720 (A) Operates as a sole proprietorship or as an independent contractor, or is an eligible self-employed individual. (B) reports farm income or expenses on a Schedule F (IRS Form 1040). And (C) was in business as of February 15, 2020. Is calculated according to (ii) or (iii) of this subsection(e)(6), depending on whether the borrower has employees. (ii) If a borrower meeting the criteria in subsection (6)(i) of this section does not have any employees, the maximum loan amount is the product obtained by multiplying.

(A) The gross income of the borrower in 2019 or 2020, as reported on a Schedule F (IRS Form 1040), that is not more than $100,000, divided by 12. And (B) 2.5. (iii) If a borrower meeting the criteria in subsection (6)(i) of this section has employees, the maximum loan amount is calculated as the lesser of. (A) The product obtained by multiplying. (1) The sum of (i) the difference between gross income and employee payroll costs of the borrower in 2019 or 2020 (at the election of the borrower), as reported on a Schedule F (IRS Form 1040), that is not more than $100,000, divided by 12, and (ii) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower.

By (2) 2.5. Or (B) $2,000,000. (7) The maximum amount of a Second Draw PPP Loan to a borrower that has income from self-employment and files a Form 1040, Schedule C, is calculated as follows, depending on whether the borrower has employees. (i) For a borrower that has income from self-employment and does not have any employees, the maximum loan amount is the lesser of. (A) The product obtained by multiplying.

(1) The net profit of the borrower in 2019 or 2020, as reported on IRS Form 1040 Schedule C, that is not more than $100,000, divided by 12. And (2) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 as defined in subsection (f)(10) at the time of disbursement, 3.5). (ii) For a borrower that has income from self-employment and has employees, the maximum loan amount is the lesser of. (A) The product obtained by multiplying. (1) The sum of (i) the net profit of the borrower in 2019 or 2020 (at the election of the borrower), as reported on IRS Form 1040 Schedule C, that is not more than $100,000, divided by 12.

(ii) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower. By (2) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5). Or (B) $2,000,000. (8) The maximum amount of a Second Draw PPP Loan to a borrower that files taxes as a partnership is calculated as the lesser of. (i) The product obtained by multiplying.

(A) The sum of (1) net earnings from self-employment of individual general partners in 2019 or 2020 (at the election of the borrower), as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed, unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties, multiplied by 0.9235,[] that is not more than $100,000, divided by 12. (2) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower. By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 as defined in subsection (f)(10) at the time of disbursal, 3.5). Or (ii) $2,000,000. (9) Businesses that are part of a single corporate group shall in no event receive more than $4,000,000 of Second Draw PPP Loans in the aggregate.

Corporate group has the same meaning as in subsection (B)(4)(f) of the Consolidated First Draw PPP IFR. (10) For purposes of calculating a borrower's maximum payroll costs, a borrower may multiply its average monthly payroll costs by 3.5 only if the borrower is in the Accommodation and Food Services sector and has reported a NAICS code beginning with 72 as its business activity code on its most recent IRS income tax return. (g) How do I submit an application for a Second Draw PPP Loan and what documentation must I provide to demonstrate eligibility?. (1) The applicant must submit to the lender SBA Form 2483-SD (Paycheck Protection Program Second Draw Borrower Application Form) or the lender's equivalent form including the required certifications and the documentation in subsection (g)(2). (2) At the time an applicant submits its loan application form, it must submit the following unless the documentation was submitted to the lender for the First Draw PPP Loan (i.e., the applicant used calendar year 2019 figures to determine both its First Draw PPP Loan amount and its Second Draw PPP Loan amount, and the lender for the applicant's Second Draw PPP Loan is the same as the lender that made the applicant's First Draw PPP Loan).

(i) If the applicant is not self-employed, the applicant's Form 941 (or other tax forms containing similar information) and state quarterly wage unemployment insurance tax reporting forms from each quarter in 2019 or 2020 (whichever was used to calculate payroll), as applicable, or equivalent payroll processor records, along with evidence of any retirement and employee group health, life, disability, vision and dental insurance contributions, must be provided. A partnership must also include its IRS Form 1065 K-1s. (ii) If the applicant is self-employed and has employees, the applicant's 2019 or 2020 (whichever was used to calculate loan amount) IRS Form 1040 Schedule C, Form 941 (or other tax forms or equivalent payroll processor records containing similar information) and state quarterly wage unemployment insurance tax reporting forms from each quarter in 2019 or 2020 (whichever was used to calculate loan amount), as applicable, or equivalent payroll processor records, along with evidence of any retirement and employee group health, life, disability, vision and dental insurance contributions, if applicable, must be provided. A payroll statement or similar documentation from the pay period that covered February 15, 2020 must be provided to establish the applicant was in operation on February 15, 2020. (iii) If the applicant is self-employed and does not have employees, the applicant must provide (a) its 2019 or 2020 (whichever was used to calculate loan amount) Form 1040 Schedule C, (b) a 2019 or 2020 (whichever was used to calculate loan amount) IRS Form 1099-MISC detailing nonemployee compensation received (box 7), invoice, bank statement, or book of record that establishes that the applicant is self-employed.

And (c) a 2020 invoice, bank statement, or book of record to establish that the applicant was in operation on or around February 15, 2020. (iv) For loans with a principal amount greater than $150,000, documentation sufficient to establish that the applicant experienced a reduction in revenue, as provided in subsection(c)(1)(iv), must be Start Printed Page 3721provided at the time of application, which may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, a copy of the applicant's quarterly income statements or bank statements. (v) For loans with a principal amount of $150,000 or less, the applicant must submit documentation sufficient to establish that the applicant experienced a reduction in revenue as provided in subsection (c)(1)(i) of this section at the time of application, on or before the date the borrower submits an application for loan forgiveness, or, if the borrower does not apply for loan forgiveness, at SBA's request. Such documentation may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, a copy of the applicant's quarterly income statements or bank statements. (3) On the Second Draw PPP Loan borrower application, an authorized representative of the applicant [] must make the certifications listed in subsection (B)(12) of the Consolidated First Draw PPP IFR, except.

(i) Instead of the certification in subsection (B)(12)(v) of the Consolidated First Draw PPP IFR, the applicant must certify that the applicant has not and will not receive another Second Draw Paycheck Protection Program Loan. And (ii) an authorized representative of the applicant must also certify. (A) The Applicant has realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period. For loans greater than $150,000, Applicant has provided documentation to the lender substantiating the decline in gross receipts. For loans of $150,000 or less, Applicant will provide documentation substantiating the decline in gross receipts upon or before seeking loan forgiveness for the Second Draw Paycheck Protection Program Loan or upon SBA request.

(B) The Applicant received a First Draw Paycheck Protection Program Loan and, before the Second Draw Paycheck Protection Program Loan is disbursed, will have used the full loan amount (including any increase) of the First Draw Paycheck Protection Program Loan only for eligible expenses. (C) The Applicant is not a business concern or entity (a) for which an entity created in or organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or that has significant operations in the People's Republic of China or the Special Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership. Or (b) that retains, as a member of the board of directors of the business concern, a person who is a resident of the People's Republic of China. (D) The Applicant is not required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C. 612).

(E) The Applicant is not a business concern or entity primarily engaged in political or lobbying activities, including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or otherwise describes itself as a think tank in any public documents. (4) A lender must submit SBA Form 2484-SD (Paycheck Protection Program Lender's Application—Second Draw Loan Guaranty) electronically in accordance with program requirements and maintain the forms and supporting documentation in its files. (h) What do lenders need to know and do?. (1) A lender approved to make First Draw PPP Loans may make Second Draw PPP Loans under the same terms and conditions applicable to First Draw PPP Loans, including all requirements under sections (C) and (D) of the Consolidated First Draw PPP IFR, except as otherwise provided in this section. (2) What do lenders have to do in terms of loan underwriting?.

(i) Each lender shall. (A) Confirm receipt of borrower certifications contained in Paycheck Protection Program Second Draw Borrower Application Form (SBA Form 2483-SD) or lender's equivalent. (B) Confirm receipt of information demonstrating that a borrower was either an eligible self-employed individual, independent contractor, or sole proprietorship with no employees or had employees for whom the borrower paid salaries and payroll taxes on or around February 15, 2020. (C) Confirm the dollar amount of average monthly payroll costs for 2019 or 2020 (whichever was used to calculate loan amount) by reviewing the payroll documentation submitted with the borrower's application. (D) For a Second Draw PPP Loan greater than $150,000 or a loan of $150,000 or less where the borrower provides documentation of revenue reduction, confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction.

For a loan of $150,000 or less where the borrower does not provide documentation of revenue reduction with its application, the lender shall perform this review when the borrower provides such documentation. If the lender identifies errors in the borrower's calculation or material lack of substantiation in the borrower's supporting documents, the lender should work with the borrower to remedy the issue. (E) Follow applicable BSA requirements (listed in subsection (C)(3)(d) of the Consolidated First Draw PPP IFR). And (ii) Each lender's underwriting obligation under the Second Draw PPP is limited to the items above and reviewing the “Paycheck Protection Program Second Draw Borrower Application Form” (SBA Form 2483-SD) or lender's equivalent form. (iii) A lender may rely on any certification or documentation submitted by an applicant for a PPP loan or an eligible recipient or eligible entity that (A) is submitted pursuant to all applicable statutory requirements, regulations, and guidance related to a PPP loan, including under sections 7(a)(36) or (37) of the Small Business Act (15 U.S.C.

636(a)(36) and (37)). And (B) attests that the applicant, eligible recipient, or eligible entity, as applicable, has accurately provided the certification or documentation to the lender in accordance with the statutory requirements, regulations, and guidance related to PPP loans. With respect to a lender that relies on such a certification or documentation related to a Second Draw PPP Loan, an enforcement action may not be taken against the lender, and the lender shall not be subject to any penalties relating to loan origination or forgiveness of the Second Draw PPP Loan, if—(A) the lender acts in good faith relating to loan origination or forgiveness of the Second Draw PPP Loan based on that reliance. And (B) all other relevant Federal, State, local, and other statutory and regulatory requirements applicable to the lender are satisfied with respect to the Second Draw PPP Loan. (3) SBA will pay lenders fees for processing Second Draw PPP Loans in the following amounts:Start Printed Page 3722 (i) for a Second Draw PPP Loan of up to (and including) $50,000, in an amount equal to the lesser of.

(A) 50 percent of the balance of the financing outstanding at the time of disbursement of the loan. Or (B) $2,500. And (ii) for a Second Draw PPP Loan of more than $50,000, in an amount that is. (A) 5 percent of the balance of the financing outstanding at the time of disbursement of the loan for a loan up to (and including) $350,000. And (B) 3 percent of the balance of the financing outstanding at the time of disbursement of the loan for a loan above $350,000.

(i) Will an applicant's Second Draw PPP Loan application be affected if there are unresolved issues regarding the applicant's First Draw PPP Loan?. (1) If a First Draw PPP Loan is under review pursuant to PPP rules and/or information in SBA's possession indicates that the borrower may have been ineligible for the First Draw PPP Loan it received or for the loan amount received by the borrower, the lender will receive notification from SBA when the lender submits an application for guaranty of a Second Draw PPP Loan (“unresolved borrower”). (2) If the lender receives notification that the Applicant for a Second Draw PPP Loan is an unresolved borrower, the lender will not receive an SBA loan number. SBA will resolve the issue related to the unresolved borrower expeditiously and will notify the lender of the process to obtain an SBA loan number for the Second Draw PPP Loan, if appropriate. (j) Are Second Draw PPP Loans eligible for loan forgiveness?.

Second Draw PPP Loans are eligible for loan forgiveness on the same terms and conditions as First Draw PPP Loans, except that Second Draw PPP Loan borrowers with a principal amount of $150,000 or less are required to provide documentation of revenue reduction if such documentation was not provided at the time of the loan application as specified in subsections (g)(2)(iv) and (v) of this section. V. Additional Information SBA may provide further guidance, if needed, through SBA notices and a program guide which will be posted on SBA's website at www.sba.gov. Questions on the Paycheck Protection Program 7(a) Loans (First Draw PPP Loans and Second Draw PPP Loans) may be directed to the Lender Relations Specialist in the local SBA Field Office. The local SBA Field Office may be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices.

Compliance With Executive Orders 12866, 12988, 13132, 13563, and 13771, the Paperwork Reduction Act (44 U.S.C. Ch. 35), and the Regulatory Flexibility Act (5 U.S.C. 601-612) Executive Orders 12866, 13563, and 13771 This interim final rule is economically significant for the purposes of Executive Orders 12866 and 13563, and the Office of Management and Budget's Office of Information and Regulatory Affairs (OIRA) had determined that this is a major rule under the Congressional Review Act (5 U.S.C. 804(2)).

SBA, however, is proceeding under the emergency provision at Executive Order 12866 section 6(a)(3)(D) based on the need to move expeditiously to mitigate the current economic conditions arising from the buy antibiotics emergency. This rule's designation under Executive Order 13771 will be informed by public comment. This rule is necessary to implement the Economic Aid Act in order to provide economic relief to small businesses nationwide adversely impacted under the buy antibiotics Emergency Declaration. We anticipate that this rule will result in substantial benefits to small businesses, their employees, and the communities they serve. However, we lack data to estimate the effects of this rule.

The Administrator of OIRA has determined that this is a major rule for purposes of the Congressional Review Act (5 U.S.C. 801 et seq.) (CRA). Under section 801(3) of the CRA, a major rule takes effect 60 days after the rule is published in the Federal Register. Notwithstanding this requirement, section 808(2) of the CRA allows agencies to dispense with the requirements of section 801 when the agency for good cause finds that such procedure would be impracticable, unnecessary, or contrary to the public interest and the rule shall take effect at such time as the agency promulgating the rule determines. Pursuant to section 808(2) of the CRA, SBA finds, for good cause, that a 60-day delay in the effective date is unnecessary and contrary to the public interest.

As discussed elsewhere in this interim final rule, the last day to apply for and receive a PPP loan is March 31, 2021. Given the short duration of this program, and the urgent need to issue loans quickly, the Administrator in consultation with the Secretary has determined that it is impractical and not in the public interest to provide a delayed effective date. An immediate effective date will give small businesses the maximum amount of time to apply for loans and lenders the maximum amount of time to process applications before the program ends. Executive Order 12988 SBA has drafted this rule, to the extent practicable, in accordance with the standards set forth in section 3(a) and 3(b)(2) of Executive Order 12988, to minimize litigation, eliminate ambiguity, and reduce burden. The rule has no preemptive or retroactive effect.

Executive Order 13132 SBA has determined that this rule will not have substantial direct effects on the States, on the relationship between the National Government and the States, or on the distribution of power and responsibilities among the various layers of government. Therefore, SBA has determined that this rule has no federalism implications warranting preparation of a federalism assessment. Paperwork Reduction Act, 44 U.S.C. Chapter 35 SBA has determined that this rule will impose new recordkeeping or reporting requirements under the Paperwork Reduction Act (“PRA”). This information collection (IC) consists of SBA Form 2483-SD (Paycheck Protection Program Second Draw Application Form) and SBA Form 2484-SD (Paycheck Protection Program Lender's Application—Second Draw Loan Guaranty.

SBA has requested emergency approval for the IC required to implement the Second Draw PPP Program described above. Regulatory Flexibility Act (RFA) The Regulatory Flexibility Act (RFA) generally requires that when an agency issues a proposed rule, or a final rule pursuant to section 553(b) of the APA or another law, the agency must prepare a regulatory flexibility analysis that meets the requirements of the RFA and publish such analysis in the Federal Register. 5 U.S.C. 603, 604. Specifically, the RFA normally requires agencies to describe the impact of a rulemaking on small entities by providing a regulatory impact analysis.

Such analysis must address the consideration of regulatory options that would lessen the economic effect of the rule on small entities. The RFA defines a “small entity” as (1) a proprietary firm meeting the size standards of the Small Business Administration (SBA). (2) a nonprofit organization that is not dominant in its field. Or (3) a small government Start Printed Page 3723jurisdiction with a population of less than 50,000. 5 U.S.C.

601(3)-(6). Except for small government jurisdictions with a population of less than 50,000, neither State nor local governments are “small entities.” The requirement to conduct a regulatory impact analysis does not apply if the head of the agency “certifies that the rule will not, if promulgated, have a significant economic impact on a substantial number of small entities.” 5 U.S.C. 605(b). The agency must, however, publish the certification in the Federal Register at the time of publication of the rule, “along with a statement providing the factual basis for such certification.” If the agency head has not waived the requirements for a regulatory flexibility analysis in accordance with the RFA's waiver provision, and no other RFA exception applies, the agency must prepare the regulatory flexibility analysis and publish it in the Federal Register at the time of promulgation or, if the rule is promulgated in response to an emergency that makes timely compliance impracticable, within 180 days of publication of the final rule. 5 U.S.C.

604(a), 608(b). Rules that are exempt from notice and comment are also exempt from the RFA requirements, including conducting a regulatory flexibility analysis, when among other things the agency for good cause finds that notice and public procedure are impracticable, unnecessary, or contrary to the public interest. Small Business Administration's Office of Advocacy guide. How to Comply with the Regulatory Flexibility Ac. Ch.1.

P.9. Since this rule is exempt from notice and comment, SBA is not required to conduct a regulatory flexibility analysis. Start Authority 15 U.S.C. 636(a)(36). antibiotics Aid, Relief, and Economic Security Act, Pub.

L. 116-136, section 1114. And Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, Pub. L. 116-260, section 303.

End Authority Start Signature Jovita Carranza, Administrator. End Signature End Supplemental Information [FR Doc. 2021-00452 Filed 1-12-21. 4:15 pm]BILLING CODE 8026-03-P.

Start Preamble where to buy generic zithromax Buy levitra online with prescription U.S. Small Business Administration. Interim final rule where to buy generic zithromax. This interim final rule announces the implementation of section 311 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act (the Economic Aid Act).

The Economic Aid Act authorizes the U.S. Small Business Administration to guarantee additional loans under the temporary Paycheck Protection Program, which was originally established under the antibiotics Aid, Relief, and Economic Security Act to provide economic relief to small businesses nationwide where to buy generic zithromax adversely impacted under the antibiotics Disease 2019 (buy antibiotics) Emergency Declaration (buy antibiotics Emergency Declaration) issued by President Trump on March 13, 2020. Section 311 of the Economic Aid Act adds a second temporary program to SBA's 7(a) Loan Program titled, “Paycheck Protection Program Second Draw Loans.” This interim final rule implements the key provisions of section 311 of the Economic Aid Act and requests public comment. Effective Date.

This interim where to buy generic zithromax final rule is effective January 12, 2021. Applicability Date. This interim final rule applies to loan applications and applications for loan forgiveness submitted for Paycheck Protection Program Second Draw Loans. Comment where to buy generic zithromax Date.

Comments must be received on or before February 16, 2021. You may submit comments, identified by number SBA-2021-0002 through the Federal eRulemaking Portal. Http://www.regulations.gov. Follow the instructions for submitting comments.

SBA will post all comments on www.regulations.gov. If you wish to submit confidential business information (CBI) as defined in the User Notice at www.regulations.gov, please send an email to ppp-ifr@sba.gov. All other comments must be submitted through the Federal eRulemaking Portal described above. Highlight the information that you consider to be CBI and explain why you believe SBA should hold this information as confidential.

SBA will review the information and make the final determination whether it will publish the information. Start Further Info Call Center Representative at 833-572-0502, or the local SBA Field Office. The list of offices can be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices. End Further Info End Preamble Start Supplemental Information I.

Background Information On December 27, 2020, President Trump signed the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act (the Economic Aid Act) (Pub. L. 116-260) into law to provide continued assistance to individuals and businesses that have been financially impacted by the ongoing antibiotics zithromax. Section 311 of the Economic Aid Act added a new temporary section 7(a)(37) to the Small Business Act (15 U.S.C.

636(a)(37)). This new section authorizes the U.S. Small Business Administration (SBA or the Administration) to guarantee Paycheck Protection Program Second Draw Loans (PPP Second Draw Program), under generally the same terms and conditions available under the Paycheck Protection Program (PPP) established under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)).

Under section 311, SBA may guarantee loans under the PPP Second Draw Program through March 31, 2021 (“Second Draw PPP Loans”) to borrowers that previously received a PPP loan under section 7(a)(36) of the Small Business Act (“First Draw PPP Loans”) and have used or will use the full amount of the initial PPP loan for authorized purposes on or before the expected date of disbursement of the Second Draw PPP Loan. Like First Draw PPP Loans, Second Draw PPP Loans are intended to provide expeditious relief to America's small Start Printed Page 3713businesses. Second Draw PPP Loans generally are guaranteed by SBA under the same terms, conditions, and processes as First Draw PPP Loans. SBA guarantees 100 percent of Second Draw PPP Loans and SBA may forgive up to the full principal loan amount.

Second Draw PPP Loans are subject to SBA's and the Department of the Treasury's (Treasury's) consolidated interim final rules implementing updates to the Paycheck Protection Program for First Draw PPP Loans (“Consolidated First Draw PPP IFR”) issued concurrently with this interim final rule (IFR) [] and all PPP loan program requirements, except as specified in this IFR. The key differences between First Draw PPP Loans and Second Draw PPP Loans are described in this IFR, which explains the loan terms, eligibility requirements, and application process for Second Draw PPP Loans. II. Comments and Immediate Effective Date This interim final rule is being issued without advance notice and public comment because section 303 of the Economic Aid Act authorizes SBA to issue regulations to implement the Economic Aid Act without regard to notice requirements.

In addition, this rule is being issued to allow for immediate implementation of this program. The intent of the Economic Aid Act is that SBA provide relief to America's small businesses expeditiously. The last day to apply for and receive a PPP loan is March 31, 2021. Given the short duration of this program, and the urgent need to issue loans quickly, the Administrator in consultation with the Secretary has determined that it is impractical and not in the public interest to provide a 30-day delayed effective date.

An immediate effective date will give small businesses the maximum amount of time to apply for loans and lenders the maximum amount of time to process applications before the program ends. This good cause justification also supports waiver of the 60-day delayed effective date for major rules under the Congressional Review Act at 5 U.S.C. 808(2). Although this IFR is effective immediately, comments are solicited from interested members of the public on all aspects of the interim final rule.

These comments must be submitted on or before February 16, 2021. SBA will consider these comments and the need for making any revisions as a result of these comments. III. Summary of Key Terms of PPP Second Draw Loans The rules applicable to Second Draw PPP Loans are published in section IV of this IFR.

This summary provides additional information and explains the key terms in the IFR. All references to subsections refer to section IV. Second Draw PPP Loans are generally subject to the same terms, conditions and requirements as First Draw PPP Loans. These include, but are not limited to the following terms.

The guarantee percentage is 100 percent. No collateral will be required. No personal guarantees will be required. The interest rate will be 100 basis points or one percent, calculated on a non-compounding, non-adjustable basis.[] The maturity is five years.

All loans will be processed by all lenders under delegated authority and lenders will be permitted to rely on certifications of the borrower to determine the borrower's eligibility and use of loan proceeds. Subsection (b) of this IFR confirms that these terms apply to Second Draw PPP Loans. Subsection (b) also confirms that SBA's Consolidated First Draw PPP IFR, Frequently Asked Questions (FAQs), and other guidance about PPP loans under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) apply to Second Draw PPP Loans, except as specified in this IFR.[] The Economic Aid Act includes terms and conditions, including but not limited to terms relating to eligibility and a borrower's maximum loan amount, that apply only to Second Draw PPP Loans and do not apply to First Draw PPP Loans, regardless of when the First Draw PPP Loan is made.

These terms and conditions specific to Second Draw PPP Loans are summarized below. A. Eligibility Requirements 1. General Eligibility Requirements In general, the Economic Aid Act made the eligibility requirements for Second Draw PPP Loans narrower than the eligibility requirements for First Draw PPP Loans.

The Economic Aid Act generally provides that a borrower is eligible for a Second Draw PPP Loan only if it has 300 or fewer employees and experienced a revenue reduction in 2020 relative to 2019 (described further below).[] In addition, the Economic Aid Act provides that a Second Draw PPP Loan may only be made to an eligible borrower that (i) has received a First Draw PPP Loan, and (ii) has used, or will use, the full amount of the First Draw PPP Loan on or before the expected date on which the Second Draw PPP Loan is disbursed to the borrower.[] Accordingly, subsections (c)(1)(i) through (c)(1)(iv) of this IFR implement these criteria. Subsection (c)(1)(ii) of the IFR clarifies that “the full amount” of the borrower's First Draw PPP Loan includes the amount of any increase on such First Draw PPP Loan made pursuant to the Economic Aid Act. In addition, subsection (c)(1)(ii) of the IFR clarifies that the borrower must have spent the full amount of its First Draw PPP Loan on eligible expenses under the PPP rules to be eligible for a Second Draw PPP Loan. This clarification will help ensure program integrity by preventing a borrower from receiving a Second Draw PPP Loan if the borrower has not complied with PPP loan program requirements.[] 2.

Revenue Reduction Requirement The Economic Aid Act provides that, to be eligible for a Second Draw PPP Loan, the borrower must have experienced a revenue reduction of 25% or greater in 2020 relative to 2019.[] A borrower must calculate this revenue reduction by comparing the borrower's quarterly gross receipts for one quarter in 2020 with the borrower's gross receipts for the corresponding quarter of 2019. For example, a borrower with gross receipts of $50,000 in the second quarter of 2019 and gross receipts of $30,000 in the second quarter of 2020 has experienced a revenue reduction of 40 percent between the quarters, and is therefore eligible for a Second Draw PPP loan (assuming all other eligibility criteria are met). Subsection (c)(1)(iv)(A) of the IFR reflects this methodology. Subsection (c)(1)(iv)(B) of the IFR provides that a borrower that was in operation in all four quarters of 2019 is deemed to have experienced the required revenue reduction if it Start Printed Page 3714experienced a reduction in annual receipts of 25 percent or greater in 2020 compared to 2019 and the borrower submits copies of its annual tax forms substantiating the revenue decline.

This provision will allow a borrower to provide annual tax return forms to substantiate its revenue reduction. The Administrator, in consultation with the Secretary of the Treasury (Secretary), has determined that this is necessary to improve administrability of Second Draw PPP Loans by providing borrowers an additional verifiable method for substantiating their revenue reduction. This method will be particularly important for small borrowers that may not have quarterly revenue information readily available. Moreover, this approach is appropriate because, if annual filings show a 25 percent revenue reduction, then at least one quarter in 2020 would have had at least a 25 percent revenue reduction.

A borrower that did not experience a 25 percent annual decline in revenues, or that was not in operation in all four quarters of 2019, may still meet the revenue reduction requirement under one of the quarterly measurements described above. The Economic Aid Act does not include a general definition of gross receipts for purposes of determining a borrower's revenue reduction.[] Subsection (c)(2) of the IFR defines gross receipts consistent with the definition of receipts in 13 CFR 121.104 of SBA's size regulations because this definition appropriately captures the type of income that is typically included in a small business's gross receipts.[] Moreover, this definition will enhance the administrability of Second Draw PPP Loans because it is a definition already used by the Administration and many small businesses. The IFR specifies that any forgiveness amount of a First Draw PPP Loan that a borrower received in calendar year 2020 is excluded from a borrower's gross receipts. Excluding the forgiveness amount from a borrower's gross receipts is consistent with section 7A(i) of the Small Business Act, which expressly excludes PPP forgiveness amounts from being taxed as income.[] This clarification ensures the effectiveness of the second draw loan program by ensuring that a borrower is not disqualified from receiving a Second Draw PPP Loan because it received forgiveness on a First Draw PPP Loan.

This furthers the purpose of the second draw loan provisions, which is to deliver additional aid to small businesses that previously received a First Draw PPP Loan. 3. Business Concerns With More Than One Physical Location Under the CARES Act, any single business entity that is assigned a NAICS code beginning with 72 (including hotels and restaurants) and employs not more than 500 employees per physical location is eligible to receive a First Draw PPP Loan.[] In addition, as discussed below, under the Consolidated First Draw PPP IFR, SBA's affiliation rules (13 CFR 121.301) do not apply to any business entity that is assigned a NAICS code beginning with 72 and that employs not more than a total of 500 employees.[] As a result, if each hotel or restaurant location owned by a parent business is a separate legal business entity and employs not more than 500 employees, each hotel or restaurant location is permitted to apply for a separate PPP loan provided it uses its unique EIN. Section 317 of the Economic Aid Act modified this provision for Second Draw PPP Loans by reducing the limit on employees per physical location to 300.

Accordingly, a single business entity that is assigned a NAICS code beginning with 72 is eligible to receive a Second Draw PPP Loan if it employs no more than 300 employees per physical location and meets the revenue reduction requirements and otherwise satisfies the eligibility criteria described in this IFR.[] Under section 317 of the Economic Aid Act, the same standard applies to certain news organizations.[] Subsections (c)(3) and (c)(4) of the IFR implement these statutory provisions. Borrowers may consult PPP Frequently Asked Question (FAQ) 24 [] for guidance on these standards for business concerns with more than one physical location, except that, for Second Draw PPP Loans, the number of employees per physical location is limited to 300 rather than 500. B. Affiliation Rules The same affiliation rules that apply to First Draw PPP Loans apply to Second Draw PPP Loans, except as provided in this IFR.

As with First Draw PPP Loans, in most cases, a borrower is considered together with its affiliates to determine eligibility for the PPP.[] However, the CARES Act waived the affiliation rules for certain categories of borrowers.[] Paragraph 7(a)(37)(E) of the Small Business Act, as amended by the Economic Aid Act, applies the same Start Printed Page 3715waivers to Second Draw PPP Loans, adds a waiver for certain eligible news organizations, and makes adjustments to reflect the reduced size requirement for Second Draw PPP Loans. Specifically, business concerns with a NAICS code beginning with 72 qualify for the affiliation waiver for Second Draw PPP Loans if they employ 300 or fewer employees. Eligible news organizations with a NAICS code beginning with 511110 or 5151 (or majority-owned or controlled by a business concern with those NAICS codes) may qualify for the affiliation waiver for Second Draw PPP Loans only if they employ 300 or fewer employees per physical location.[] Subsection (d)(2) implements these revised affiliation waivers. SBA also adopted a religious exemption to the affiliation rules by regulation,[] which applies to Second Draw PPP loans.

C. Excluded Entities An entity that is ineligible to receive a First Draw PPP Loan under the CARES Act or Consolidated First Draw PPP IFR is also ineligible for a Second Draw PPP Loan.[] Subsection (e)(1) of the IFR implements this restriction. Subsection (e)(1) ensures that a borrower that received a First Draw PPP Loan despite being ineligible to receive the loan is not eligible to receive a Second Draw PPP Loan. The Economic Aid Act also prohibits several additional categories of borrowers from receiving a Second Draw PPP Loan under section 7(a)(37) of the Small Business Act.

These categories of prohibited borrowers are listed in subsection (e) of the IFR. A business concern or entity primarily engaged in political activities or lobbying activities, including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or that describes itself as a think tank in any public documents; [] certain entities organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or with other specified ties to the People's Republic of China or the Special Administrative Region of Hong Kong; [] any person required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C. 612); [] a person or entity that receives a grant for shuttered venue operators under section 324 of the Economic Aid Act; [] entities in which the President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person owns, controls, or holds at least 20 percent of any class of equity; [] or a publicly traded company, defined as an issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the Securities Exchange Act of 1934 (15 U.S.C. 78f).[] In addition, subsection (e)(9) of this IFR provides that an entity that has previously received a Second Draw PPP Loan may not receive another Second Draw PPP Loan, as required by the Economic Aid Act.[] Subsection (e)(9) also prohibits an entity that has permanently closed from receiving a Second Draw PPP Loan because paragraph 7(a)(37)(A)(iv) of the Small Business Act is best understood to describe existing businesses.

The Administrator, in consultation with the Secretary, has determined this provision is also necessary to maintain program integrity, prevent abuse, and preserve the availability of Second Draw PPP Loan funds for businesses still in operation. Preserving funds for such businesses is necessary because only businesses that are still in operation will retain employees, which is a primary purpose of the PPP. A borrower that has temporarily closed or temporarily suspended its business remains eligible for a Second Draw PPP Loan. D.

Payroll Cost Calculation In general, section 307 of the Economic Aid Act provides that the maximum loan amount for a Second Draw PPP Loan is equal to the lesser of two and half months of the borrower's average monthly payroll costs or $2 million. Relative to First Draw PPP loans, the Economic Aid Act adjusted the methodology for calculating a borrower's payroll costs. Unlike First Draw PPP Loans, the Economic Aid Act provides that the relevant time period for calculating a borrower's payroll costs for a Second Draw PPP Loan is either the twelve-month period prior to when the loan is made or calendar year 2019. The Act also provided tailored methodologies for certain categories of borrowers.

These calculations are reflected in subsection (f) of this IFR. Subsection (f) of the IFR uses “calendar year 2020” to refer to “the twelve-month period prior to when the loan is made.” Calculating payroll costs based on calendar year 2020 rather than the twelve months preceding the date the loan is made will simplify the calculations and documentation requirements for borrowers because payroll records are more commonly created and retained on a calendar-year basis. Allowing borrowers to calculate payroll costs based on calendar year 2020 is also not expected to result in a significant difference in payroll costs compared to the twelve months preceding the date the loan is made because all Second Draw PPP Loans will be made in the first quarter of 2021. However, the rule notes that Second Draw PPP Loan borrowers who are not self-employed (including sole proprietorships and independent contractors) are also permitted to use the precise 1-year period before the date on which the loan is made to calculate payroll costs if they choose not to use 2019 or 2020 to calculate payroll costs.

Consistent with the Economic Aid Act, subsections (f)(3) and (f)(4) of the IFR include tailored calculation methodologies for seasonal businesses, new entities that did not exist for the full twelve-month period preceding the Second Draw PPP Loan, and borrowers assigned a NAICS code beginning with 72 at the time of disbursement. For borrowers assigned a NAICS code beginning with 72 at the time of disbursement, the Economic Aid Act provides that the maximum loan amount is equal to three-and-a-half (3.5) months of payroll costs rather than two-and-a-half (2.5) months.[] These subsections also provide that, for a borrower with a NAICS code beginning with 72 that would fall into more than one category listed in subsection (f) (for example, a business with a NAICS code beginning with 72 that is also a seasonal business or is also a new entity without 12 months of payroll costs), the borrower may calculate its average monthly payroll costs based on the methodology that applies to the entity but may use the 3.5 multiplier Start Printed Page 3716applicable to businesses with a NAICS code beginning with 72. The Administrator, in consultation with the Secretary, has determined that this methodology is necessary to provide small businesses in the accommodation and food services sector the full amount of relief provided in the Economic Aid Act while allowing these borrowers to calculate their average monthly payroll costs accurately. The Economic Aid Act included a new payroll cost calculation for farmers and ranchers receiving First Draw PPP Loans.

However, it did not specify how payroll costs should be calculated for Second Draw PPP Loans to farmers and ranchers. This IFR clarifies that the same general calculation for farmers and ranchers applicable to First Draw PPP Loans applies to Second Draw PPP Loans, with adjustments that (i) eliminate the provision for refinancing of an Economic Injury Disaster Loan (EIDL), which does not apply to Second Draw PPP Loans, and (ii) apply the choice of time period for calculating a farmer's or rancher's payroll costs for Second Draw PPP Loans, consistent with other Second Draw PPP Loans. This IFR also specifies that, in calculating a farmer's or rancher's maximum loan amount, any employee payroll costs should be subtracted from the farmer's or rancher's gross income to avoid double-counting amounts that represent pay to the employees of the farmer or rancher. Subsections (f)(7) and (f)(8) of the IFR include tailored calculation methodologies for self-employed individuals and partnerships.

These methodologies are based on the corresponding methodologies for self-employed individuals and partnerships that are used for First Draw PPP Loans.[] These methodologies have been adjusted to eliminate the provision for refinancing of an EIDL loan, which does not apply to Second Draw PPP loans and to apply the choice of time period for calculating payroll costs, consistent with other Second Draw PPP loans. Finally, subsection (f)(9) provides that businesses that are part of a single corporate group shall in no event receive more than $4,000,000 of Second Draw PPP Loans in the aggregate. The Administrator, in consultation with the Secretary, determined that limiting the amount of Second Draw PPP Loans that a single corporate group may receive will promote the availability of PPP loans to the largest possible number of borrowers, consistent with the CARES and Economic Aid Act. The Administrator has concluded that a limitation of $4,000,000 is appropriate because it is proportional to the $20,000,000 maximum amount for corporate groups that is provided under the Consolidated First Draw PPP IFR when the maximum loan amount for a single PPP loan is $10,000,000.

E. Second Draw PPP Loan Application and Documentation Requirements Subsection (g) of this IFR includes the application and documentation requirements for Second Draw PPP Loans. The documentation required to substantiate an applicant's payroll cost calculations is generally the same as documentation required for First Draw PPP Loans. However, no additional documentation to substantiate payroll costs will be required if the applicant (i) used calendar year 2019 figures to determine its First Draw PPP Loan amount, (ii) used calendar year 2019 figures to determine its Second Draw PPP Loan amount (instead of calendar year 2020), and (iii) the lender for the applicant's Second Draw PPP Loan is the same as the lender that made the applicant's First Draw PPP Loan.

In such cases, additional documentation is not required because the lender already has the relevant documentation supporting the borrower's payroll costs. The lender may request additional documentation, however, if on further review the lender concludes that it would be useful in conducting the lender's good-faith review of the borrower's loan amount calculation. For loans with a principal amount greater than $150,000, the applicant must also submit documentation adequate to establish that the applicant experienced a revenue reduction of 25% or greater in 2020 relative to 2019. (The revenue reduction requirement is addressed in subsection (c)(1)(iv) of this IFR.) Such documentation may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, quarterly financial statements or bank statements.

For loans with a principal amount of $150,000 or less, such documentation is not required at the time the borrower submits its application for a loan, but must be submitted on or before the date the borrower applies for loan forgiveness, as required under the Economic Aid Act.[] If a borrower does not submit an application for loan forgiveness, such documentation must be provided upon SBA's request. F. Lender Requirements Subsection (g) of this IFR contains the provisions specific to lenders for Second Draw PPP Loans. Paragraph 7(a)(37)(K) of the Small Business Act, added by the Economic Aid Act, states that a lender approved to make First Draw PPP loans may make Second Draw PPP Loans under the same terms and conditions as new First Draw PPP Loans.

Subsection (g)(2) of this IFR provides that lenders are subject to the same requirements when making Second Draw PPP Loans as when they are making First Draw PPP Loans. These provisions allow a lender approved to make Second Draw PPP Loans to use existing program guidance and standard operating procedures to the maximum extent practicable.[] The requirements applicable to PPP lenders are in sections (C) and (D) of the Consolidated First Draw PPP IFR. If a borrower has not submitted new payroll documentation with its Second Draw PPP Loan application because it previously submitted 2019 payroll information to the same lender when it applied for its First Draw PPP Loan, then the lender must confirm the borrower's average monthly payroll costs based on that prior documentation. In addition, for a Second Draw PPP Loan greater than $150,000, the lender must confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction.

If the lender identifies errors in the borrower's calculation or a material lack of substantiation in the borrower's supporting documents, the lender should work with the borrower to remedy the issue. G. Loans to Borrowers With Unresolved First Draw PPP Loans As described in SBA's interim final rule on SBA Loan Review Procedures and Related Borrower and Lender Responsibilities, SBA may review any PPP loan, as the Administrator deems appropriate.[] Subsection (i) of the IFR establishes procedures relating to the handling of a Second Draw PPP Loan application by a borrower whose First Draw PPP Loan is under review by SBA (“unresolved borrower”). If a borrower's First Draw PPP loan is under review by SBA and/or information in SBA's possession indicates that the borrower may have been ineligible for the First Start Printed Page 3717Draw PPP Loan it received or for the loan amount it received, the lender will receive notification from SBA when the lender submits an application for a guaranty of a Second Draw PPP Loan and will not receive an SBA loan number until the issue related to the unresolved borrower's First Draw PPP Loan is resolved.

SBA will resolve issues related to unresolved borrowers expeditiously. These procedures are designed to promote compliance with the eligibility requirements for Second Draw PPP Loans by preventing additional loans from being made to borrowers that were not eligible for a First Draw PPP Loan or received an impermissible loan amount. At the same time, these procedures do not disqualify an eligible unresolved borrower from receiving a Second Draw PPP Loan, in recognition that many flags will be resolved in the borrower's favor. The Administrator, in consultation with the Secretary, has determined that these procedures strike an appropriate balance between promoting program integrity and preventing abuse, while making Second Draw PPP Loans available to all eligible borrowers as expeditiously as possible.

SBA will set aside available appropriations to fund Second Draw PPP Loans applied for by unresolved borrowers in the event they are approved. H. Loan Forgiveness Loan forgiveness of Second Draw PPP Loans and the loan review process for Second Draw PPP Loans are generally subject to the interim final rules regarding Loan Forgiveness and SBA Loan Review Procedures and Related Borrower and Lender Responsibilities, as modified to conform to the Economic Aid Act by the Consolidated First Draw PPP IFR, which is being published concurrently with this IFR. Subsection (j) contains forgiveness provisions specific to Second Draw PPP loans.

Table of Contents (a) Second Draw PPP Loan Program (b) What requirements apply to Second Draw PPP Loans?. (c) Who is eligible for a Second Draw PPP Loan?. (d) How do SBA's affiliation rules affect an applicant's eligibility for a Second Draw PPP Loan?. (e) Who is not eligible for a Second Draw PPP Loan?.

(f) What is the maximum loan amount for a Second Draw PPP Loan?. (g) How do I submit an application for a Second Draw PPP Loan and what documentation must I provide to demonstrate eligibility?. (h) What do lenders need to know and do?. (i) Will an applicant's Second Draw PPP Loan application be affected if there are unresolved issues regarding the applicant's First Draw PPP Loan?.

(j) Are Second Draw PPP Loans eligible for loan forgiveness?. IV. Paycheck Protection Program Second Draw Loans (a) Second Draw PPP Loan Program Under section 7(a)(37) of the Small Business Act (15 U.S.C. 636(a)(37)), SBA is authorized to guarantee Paycheck Protection Program Second Draw Loans (“Second Draw PPP Loans”).

(b) What requirements apply to Second Draw PPP Loans?. (1) Second Draw PPP Loans are subject to SBA's and the Department of the Treasury's (“Treasury's”) consolidated interim final rule implementing the Paycheck Protection Program (“Consolidated First Draw PPP IFR”) and all PPP loan program requirements, except as otherwise provided in this section, including but not limited to the following terms. (i) The guarantee percentage is 100 percent. (ii) No collateral will be required.

(iii) No personal guarantees will be required. (iv) The interest rate will be 100 basis points or one percent, calculated on a non-compounding, non-adjustable basis. (v) The maturity is five years. (vi) All loans will be processed by all lenders under delegated authority and lenders will be permitted to rely on certifications of the borrower in order to determine eligibility of the borrower and the use of loan proceeds.

(2) Frequently Asked Questions and other guidance issued by SBA or by SBA in consultation with the Department of the Treasury with respect to PPP loans under section 7(a)(36) of the Small Business Act (15 U.S.C. 636(a)(36)) (“First Draw PPP Loans”) apply to Second Draw PPP Loans, except as otherwise provided in this section. (c) Who is eligible for a Second Draw PPP Loan?. Subject to subsection (e) of this section, below, the following applicants are eligible for Second Draw PPP Loans.

(1) An applicant is eligible for a Second Draw PPP Loan if it is a business concern, independent contractor, eligible self-employed individual, sole proprietor, nonprofit organization eligible for a First Draw PPP Loan, veterans organization, Tribal business concern, housing cooperative, small agricultural cooperative, eligible 501(c)(6) organization or destination marketing organization, or an eligible nonprofit news organization [] that. (i) Previously received a First Draw PPP loan in accordance with the eligibility criteria in the Consolidated First Draw PPP IFR. (ii) has used, or will use, the full amount of its First Draw PPP Loan (including the amount of any increase on such First Draw PPP Loan) on authorized uses under subsection (B)(11) of the Consolidated First Draw PPP IFR on or before the expected date on which the Second Draw PPP Loan will be disbursed; [] (iii) employs not more than 300 employees, unless it satisfies the alternative criteria for businesses with a North American Industry Classification System (“NAICS”) code beginning with 72 and eligible news organizations with more than one physical location described in subsection (c)(3) or (c)(4) of this section. And (iv) (A) experienced a reduction in revenue in calendar year 2020, measured as follows.

(1) the applicant had gross receipts during the first, second, third, or fourth quarter in 2020 that demonstrate at least a 25 percent reduction from the applicant's gross receipts during the same quarter in 2019 (for example, an applicant that had gross receipts of $50,000 in the second quarter of 2019 and had gross receipts of $30,000 in the second quarter of 2020 experienced a 40 percent revenue reduction between these two quarters). (2) if the applicant was not in business during the first or second quarter of 2019, but was in business during the third and fourth quarters of 2019, the applicant had gross receipts during the first, second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the applicant's gross receipts during the third or fourth quarter of 2019 (for example, an applicant that had gross receipts of $50,000 in the third quarter of 2019 and had gross receipts of $30,000 in the third quarter of 2020-demonstrating a reduction of 40 percent from the applicant's gross receipts during the third quarter in 2019). (3) if the applicant was not in business during the first, second, or third quarter of 2019, but was in business during the fourth quarter of 2019, the applicant had gross receipts Start Printed Page 3718during the first, second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the fourth quarter of 2019 (for example, an applicant that had gross receipts of $50,000 in the fourth quarter of 2019 and had gross receipts of $30,000 in the fourth quarter of 2020-demonstrating a reduction of 40 percent from the applicant's gross receipts during the fourth quarter in 2019). Or (4) if the applicant was not in business during 2019, but was in operation on February 15, 2020, the applicant had gross receipts during the second, third, or fourth quarter of 2020 that demonstrate at least a 25 percent reduction from the gross receipts of the entity during the first quarter of 2020 (for example, an applicant that had gross receipts of $50,000 in the first quarter of 2020 and had gross receipts of $30,000 in the fourth quarter of 2020—demonstrating a reduction of 40 percent from the applicant's gross receipts during the first quarter in 2020).

(B) An applicant that was in operation in all four quarters of 2019 is deemed to have experienced the revenue reduction in subsection (c)(1)(iv)(A)(1) if it experienced a reduction in annual receipts of 25 percent or greater in 2020 compared to 2019 and the borrower submits copies of its annual tax forms substantiating the revenue decline. (2)(i) Gross receipts includes all revenue in whatever form received or accrued (in accordance with the entity's accounting method) from whatever source, including from the sales of products or services, interest, dividends, rents, royalties, fees, or commissions, reduced by returns and allowances. Generally, receipts are considered “total income” (or in the case of a sole proprietorship, independent contractor, or self-employed individual “gross income”) plus “cost of goods sold,” and excludes net capital gains or losses as these terms are defined and reported on IRS tax return forms. Gross receipts do not include the following.

Taxes collected for and remitted to a taxing authority if included in gross or total income (such as sales or other taxes collected from customers and excluding taxes levied on the concern or its employees). Proceeds from transactions between a concern and its domestic or foreign affiliates. And amounts collected for another by a travel agent, real estate agent, advertising agent, conference management service provider, freight forwarder or customs broker. All other items, such as subcontractor costs, reimbursements for purchases a contractor makes at a customer's request, investment income, and employee-based costs such as payroll taxes, may not be excluded from gross receipts.

(ii) Gross receipts of affiliates are calculated as follows. (A) Gross receipts of a borrower with affiliates is calculated by adding the gross receipts of the business concern with the gross receipts of each affiliate. (B) If a borrower has acquired an affiliate or been acquired as an affiliate during 2020, gross receipts includes the receipts of the acquired or acquiring concern. This aggregation applies for the entire period of measurement, not just the period after the affiliation arose.

However, if a concern acquired a segregable division of another business concern during 2020, gross receipts do not include the receipts of the acquired division prior to the acquisition. (C) The gross receipts of a former affiliate are not included. This exclusion of gross receipts of such former affiliate applies during the entire period of measurement, rather than only for the period after which affiliation ceased. However, if a borrower sold a segregable division during 2020, the gross receipts will continue to include the receipts of the division that was sold.

(D) All terms in this subsection shall have the meaning attributed to them by the IRS. (iii) For an eligible nonprofit organization, a veterans organization, an eligible nonprofit news organization, an eligible 501(c)(6) organization, or eligible destination marketing organization, gross receipts means gross receipts within the meaning of section 6033 of the Internal Revenue Code of 1986. (iv) The amount of any forgiven First Draw PPP Loan shall not be included toward any borrower's gross receipts. (3) Any business concern that has more than one physical location and that employs not more than 300 employees per physical location is eligible to receive a Second Draw PPP Loan if it is assigned a NAICS code beginning with 72 at the time of loan disbursement and otherwise meets the eligibility criteria in subsection (c)(1).

(4) Any business concern, or any station which broadcasts pursuant to a license granted by the Federal Communications Commission under title III of the Communications Act of 1934 (47 U.S.C. 301 et seq.), that has more than one physical location and that employs not more than 300 employees per physical location is eligible to receive a Second Draw PPP Loan if it meets the eligibility criteria in subsection (c)(1) and. (1) Is majority owned or controlled by a business concern that is assigned a NAICS code beginning with 511110 or 5151 or, with respect to a public broadcasting entity (as defined in section 397(11) of the Communications Act of 1934 (47 U.S.C. 397(11))), has a trade or business that falls under such a code.

And (2) makes a good faith certification that proceeds of the loan will be used to support expenses at the component of the organization that produces or distributes locally focused or emergency information. (d) How do SBA's affiliation rules affect an applicant's eligibility for a Second Draw PPP Loan?. (1) Eligibility for Second Draw PPP Loans is governed by the same affiliations rules (and waivers) as First Draw PPP Loans, except as described in subsection (d)(2). (2) The affiliation rules under 13 CFR 121.301(f) are waived with respect to eligibility for a Second Draw PPP Loan for.

(i) Any business concern with not more than 300 employees that, as of the date on which the covered loan is disbursed, is assigned a NAICS code beginning with 72. And (ii) (A) any business concern (including any station which broadcasts pursuant to a license granted by the Federal Communications Commission under title III of the Communications Act of 1934 (47 U.S.C. 301 et seq.) without regard for whether such a station is a concern as defined in 13 CFR 121.105, or any successor thereto) that employs not more than 300 employees, per physical location of such business concern and is majority owned or controlled by a business concern that is assigned a NAICS code beginning with 511110 or 5151. Or (B) any nonprofit organization that is assigned a NAICS code beginning with 5151.

(e) Who is not eligible for a Second Draw PPP Loan?. An applicant is not eligible for a Second Draw PPP Loan, even if it meets the eligibility requirements of subsection (c) of this section, if the applicant is. (1) Excluded from eligibility under the Consolidated First Draw PPP IFR; [] (2) a business concern or entity primarily engaged in political activities or lobbying activities, as defined in section 3 of the Lobbying Disclosure Act of 1995 (2 U.S.C. 1602), including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or Start Printed Page 3719otherwise describes itself as a think tank in any public documents.

(3) any business concern or entity. (i) For which an entity created in or organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or that has significant operations in the People's Republic of China or the Special Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership. Or (ii) that retains, as a member of the board of directors of the business concern, a person who is a resident of the People's Republic of China. (4) any person required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C.

612). (5) any person or entity that receives a grant for shuttered venue operators under section 324 of the Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act. (6) any entity in which the President, the Vice President, the head of an Executive department, or a Member of Congress, or the spouse of such person as determined under applicable common law, directly or indirectly holds a controlling interest in the entity, where. (i) “controlling interest” means owning, controlling, or holding not less than 20 percent, by vote or value, of the outstanding amount of any class of equity interest in an entity.

(ii) “equity interest” means. (A) A share in an entity, without regard to whether the share is transferable or classified as stock or anything similar. (B) a capital or profit interest in a limited liability company or partnership. Or (C) a warrant or right, other than a right to convert, to purchase, sell, or subscribe to a share or interest described in (A) or (B), respectively.

(iii) “Executive department” has the meaning given the term in section 101 of title 5, United States Code. (iv) “Member of Congress” means a Member of the Senate or House of Representatives, a Delegate to the House of Representatives, and the Resident Commissioner from Puerto Rico. And (v) For the purpose of determining whether a person has a controlling interest in the entity, the securities owned, controlled, or held by the President, the Vice President, the head of an Executive department, or a Member of Congress, shall be aggregated with the securities held by his or her spouse as determined under applicable common law. (7) any issuer, the securities of which are listed on an exchange registered as a national securities exchange under section 6 of the Securities Exchange Act of 1934 (15 U.S.C.

78f), where the terms “exchange,” “issuer,” and “security” have the meanings given those terms in section 3(a) of the Securities Exchange Act of 1934 (15 U.S.C. 78c(a)) (except SBA will not consider whether a news organization that is eligible under subsection (c)(4) is affiliated with an entity, which includes any entity that owns or controls such news organization, that is an issuer). (8) an entity that has previously received a Second Draw PPP Loan. Or (9) an entity that has permanently closed.

(f) What is the maximum loan amount for a Second Draw PPP Loan?. (1) In general, the maximum loan amount for a Second Draw PPP Loan is equal to the lesser of two and half months of the borrower's average monthly payroll costs or $2 million, except as otherwise specified in this subsection (e). A borrower's average monthly payroll costs may be based on calendar year 2020, calendar year 2019,[] or as otherwise specified in subsections (f)(2) through (f)(9) of this section. €œPayroll costs” has the same meaning as in subsections (B)(4)(g) and (B)(4)(h) of the Consolidated First Draw PPP IFR and is calculated in the same manner.

In calculating a borrower's payroll costs, the borrower must subtract any compensation paid to an employee in excess of $100,000 on an annualized basis, as prorated for the time period during which the payments are made or the obligation to make the payments is incurred. (2) Except as otherwise provided in subsection (f)(3) through (f)(7), the maximum amount of a Second Draw PPP Loan is calculated as the lesser of. (i) The product obtained by multiplying. (A) The average total monthly payment for payroll costs incurred or paid by the borrower during 2019 or 2020 (at the election of the borrower).

By (B) 2.5. Or (ii) $2,000,000. (3) The maximum amount of a Second Draw PPP Loan to a borrower that is a seasonal employer (meaning an employer that does not operate for more than 7 months in any calendar year or that during the preceding calendar year, had gross receipts for any 6 months of that year that were not more than 33.33 percent of the gross receipts of the employer for the other 6 months of that year) is calculated as the lesser of. (i) The product obtained by multiplying.

(A) At the election of the borrower, the average total monthly payments for payroll costs incurred or paid by the borrower for any 12-week period between February 15, 2019 and February 15, 2020. By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5). Or (ii) $2,000,000. (4) The maximum amount of a Second Draw PPP Loan to a borrower that did not exist during the 1-year period preceding February 15, 2020, but was in operation on February 15, 2020 (“new entity”), is calculated as the lesser of.

(i) The product obtained by multiplying. (A) The quotient obtained by dividing. (1) The sum of the total monthly payments by the borrower for payroll costs paid or incurred by the borrower as of the date on which the borrower applies for the Second Draw PPP Loan. By (2) the number of months in which those payroll costs were paid or incurred.

By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5). Or (ii) $2,000,000. (5) The maximum amount of a Second Draw PPP Loan made to a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10) (that is not a seasonal employer or new entity addressed in subsection (f)(3) or (f)(4) or a borrower with self-employment income or a partnership addressed in subsection (f)(7) or (f)(8) of this section) is calculated as the lesser of. (i) The product obtained by multiplying.

(A) The average total monthly payment for payroll costs incurred or paid by the borrower during either 2019 or 2020 (at the borrower's election) by (B) 3.5. Or (ii) $2,000,000. (6) (i) The maximum amount of a Second Draw PPP Loan to a farmer or rancher that:Start Printed Page 3720 (A) Operates as a sole proprietorship or as an independent contractor, or is an eligible self-employed individual. (B) reports farm income or expenses on a Schedule F (IRS Form 1040).

And (C) was in business as of February 15, 2020. Is calculated according to (ii) or (iii) of this subsection(e)(6), depending on whether the borrower has employees. (ii) If a borrower meeting the criteria in subsection (6)(i) of this section does not have any employees, the maximum loan amount is the product obtained by multiplying. (A) The gross income of the borrower in 2019 or 2020, as reported on a Schedule F (IRS Form 1040), that is not more than $100,000, divided by 12.

And (B) 2.5. (iii) If a borrower meeting the criteria in subsection (6)(i) of this section has employees, the maximum loan amount is calculated as the lesser of. (A) The product obtained by multiplying. (1) The sum of (i) the difference between gross income and employee payroll costs of the borrower in 2019 or 2020 (at the election of the borrower), as reported on a Schedule F (IRS Form 1040), that is not more than $100,000, divided by 12, and (ii) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower.

By (2) 2.5. Or (B) $2,000,000. (7) The maximum amount of a Second Draw PPP Loan to a borrower that has income from self-employment and files a Form 1040, Schedule C, is calculated as follows, depending on whether the borrower has employees. (i) For a borrower that has income from self-employment and does not have any employees, the maximum loan amount is the lesser of.

(A) The product obtained by multiplying. (1) The net profit of the borrower in 2019 or 2020, as reported on IRS Form 1040 Schedule C, that is not more than $100,000, divided by 12. And (2) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 as defined in subsection (f)(10) at the time of disbursement, 3.5). (ii) For a borrower that has income from self-employment and has employees, the maximum loan amount is the lesser of.

(A) The product obtained by multiplying. (1) The sum of (i) the net profit of the borrower in 2019 or 2020 (at the election of the borrower), as reported on IRS Form 1040 Schedule C, that is not more than $100,000, divided by 12. (ii) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower. By (2) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 at the time of disbursement as defined in subsection (f)(10), 3.5).

Or (B) $2,000,000. (8) The maximum amount of a Second Draw PPP Loan to a borrower that files taxes as a partnership is calculated as the lesser of. (i) The product obtained by multiplying. (A) The sum of (1) net earnings from self-employment of individual general partners in 2019 or 2020 (at the election of the borrower), as reported on IRS Form 1065 K-1, reduced by section 179 expense deduction claimed, unreimbursed partnership expenses claimed, and depletion claimed on oil and gas properties, multiplied by 0.9235,[] that is not more than $100,000, divided by 12.

(2) the average total monthly payment for employee payroll costs incurred or paid by the borrower during the same year elected by the borrower. By (B) 2.5 (or, only for a borrower assigned a NAICS code beginning with 72 as defined in subsection (f)(10) at the time of disbursal, 3.5). Or (ii) $2,000,000. (9) Businesses that are part of a single corporate group shall in no event receive more than $4,000,000 of Second Draw PPP Loans in the aggregate.

Corporate group has the same meaning as in subsection (B)(4)(f) of the Consolidated First Draw PPP IFR. (10) For purposes of calculating a borrower's maximum payroll costs, a borrower may multiply its average monthly payroll costs by 3.5 only if the borrower is in the Accommodation and Food Services sector and has reported a NAICS code beginning with 72 as its business activity code on its most recent IRS income tax return. (g) How do I submit an application for a Second Draw PPP Loan and what documentation must I provide to demonstrate eligibility?. (1) The applicant must submit to the lender SBA Form 2483-SD (Paycheck Protection Program Second Draw Borrower Application Form) or the lender's equivalent form including the required certifications and the documentation in subsection (g)(2).

(2) At the time an applicant submits its loan application form, it must submit the following unless the documentation was submitted to the lender for the First Draw PPP Loan (i.e., the applicant used calendar year 2019 figures to determine both its First Draw PPP Loan amount and its Second Draw PPP Loan amount, and the lender for the applicant's Second Draw PPP Loan is the same as the lender that made the applicant's First Draw PPP Loan). (i) If the applicant is not self-employed, the applicant's Form 941 (or other tax forms containing similar information) and state quarterly wage unemployment insurance tax reporting forms from each quarter in 2019 or 2020 (whichever was used to calculate payroll), as applicable, or equivalent payroll processor records, along with evidence of any retirement and employee group health, life, disability, vision and dental insurance contributions, must be provided. A partnership must also include its IRS Form 1065 K-1s. (ii) If the applicant is self-employed and has employees, the applicant's 2019 or 2020 (whichever was used to calculate loan amount) IRS Form 1040 Schedule C, Form 941 (or other tax forms or equivalent payroll processor records containing similar information) and state quarterly wage unemployment insurance tax reporting forms from each quarter in 2019 or 2020 (whichever was used to calculate loan amount), as applicable, or equivalent payroll processor records, along with evidence of any retirement and employee group health, life, disability, vision and dental insurance contributions, if applicable, must be provided.

A payroll statement or similar documentation from the pay period that covered February 15, 2020 must be provided to establish the applicant was in operation on February 15, 2020. (iii) If the applicant is self-employed and does not have employees, the applicant must provide (a) its 2019 or 2020 (whichever was used to calculate loan amount) Form 1040 Schedule C, (b) a 2019 or 2020 (whichever was used to calculate loan amount) IRS Form 1099-MISC detailing nonemployee compensation received (box 7), invoice, bank statement, or book of record that establishes that the applicant is self-employed. And (c) a 2020 invoice, bank statement, or book of record to establish that the applicant was in operation on or around February 15, 2020. (iv) For loans with a principal amount greater than $150,000, documentation sufficient to establish that the applicant experienced a reduction in revenue, as provided in subsection(c)(1)(iv), must be Start Printed Page 3721provided at the time of application, which may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, a copy of the applicant's quarterly income statements or bank statements.

(v) For loans with a principal amount of $150,000 or less, the applicant must submit documentation sufficient to establish that the applicant experienced a reduction in revenue as provided in subsection (c)(1)(i) of this section at the time of application, on or before the date the borrower submits an application for loan forgiveness, or, if the borrower does not apply for loan forgiveness, at SBA's request. Such documentation may include relevant tax forms, including annual tax forms, or, if relevant tax forms are not available, a copy of the applicant's quarterly income statements or bank statements. (3) On the Second Draw PPP Loan borrower application, an authorized representative of the applicant [] must make the certifications listed in subsection (B)(12) of the Consolidated First Draw PPP IFR, except. (i) Instead of the certification in subsection (B)(12)(v) of the Consolidated First Draw PPP IFR, the applicant must certify that the applicant has not and will not receive another Second Draw Paycheck Protection Program Loan.

And (ii) an authorized representative of the applicant must also certify. (A) The Applicant has realized a reduction in gross receipts in excess of 25% relative to the relevant comparison time period. For loans greater than $150,000, Applicant has provided documentation to the lender substantiating the decline in gross receipts. For loans of $150,000 or less, Applicant will provide documentation substantiating the decline in gross receipts upon or before seeking loan forgiveness for the Second Draw Paycheck Protection Program Loan or upon SBA request.

(B) The Applicant received a First Draw Paycheck Protection Program Loan and, before the Second Draw Paycheck Protection Program Loan is disbursed, will have used the full loan amount (including any increase) of the First Draw Paycheck Protection Program Loan only for eligible expenses. (C) The Applicant is not a business concern or entity (a) for which an entity created in or organized under the laws of the People's Republic of China or the Special Administrative Region of Hong Kong, or that has significant operations in the People's Republic of China or the Special Administrative Region of Hong Kong, owns or holds, directly or indirectly, not less than 20 percent of the economic interest of the business concern or entity, including as equity shares or a capital or profit interest in a limited liability company or partnership. Or (b) that retains, as a member of the board of directors of the business concern, a person who is a resident of the People's Republic of China. (D) The Applicant is not required to submit a registration statement under section 2 of the Foreign Agents Registration Act of 1938 (22 U.S.C.

612). (E) The Applicant is not a business concern or entity primarily engaged in political or lobbying activities, including any entity that is organized for research or for engaging in advocacy in areas such as public policy or political strategy or otherwise describes itself as a think tank in any public documents. (4) A lender must submit SBA Form 2484-SD (Paycheck Protection Program Lender's Application—Second Draw Loan Guaranty) electronically in accordance with program requirements and maintain the forms and supporting documentation in its files. (h) What do lenders need to know and do?.

(1) A lender approved to make First Draw PPP Loans may make Second Draw PPP Loans under the same terms and conditions applicable to First Draw PPP Loans, including all requirements under sections (C) and (D) of the Consolidated First Draw PPP IFR, except as otherwise provided in this section. (2) What do lenders have to do in terms of loan underwriting?. (i) Each lender shall. (A) Confirm receipt of borrower certifications contained in Paycheck Protection Program Second Draw Borrower Application Form (SBA Form 2483-SD) or lender's equivalent.

(B) Confirm receipt of information demonstrating that a borrower was either an eligible self-employed individual, independent contractor, or sole proprietorship with no employees or had employees for whom the borrower paid salaries and payroll taxes on or around February 15, 2020. (C) Confirm the dollar amount of average monthly payroll costs for 2019 or 2020 (whichever was used to calculate loan amount) by reviewing the payroll documentation submitted with the borrower's application. (D) For a Second Draw PPP Loan greater than $150,000 or a loan of $150,000 or less where the borrower provides documentation of revenue reduction, confirm the dollar amount and percentage of the borrower's revenue reduction by performing a good faith review, in a reasonable time, of the borrower's calculations and supporting documents concerning the borrower's revenue reduction. For a loan of $150,000 or less where the borrower does not provide documentation of revenue reduction with its application, the lender shall perform this review when the borrower provides such documentation.

If the lender identifies errors in the borrower's calculation or material lack of substantiation in the borrower's supporting documents, the lender should work with the borrower to remedy the issue. (E) Follow applicable BSA requirements (listed in subsection (C)(3)(d) of the Consolidated First Draw PPP IFR). And (ii) Each lender's underwriting obligation under the Second Draw PPP is limited to the items above and reviewing the “Paycheck Protection Program Second Draw Borrower Application Form” (SBA Form 2483-SD) or lender's equivalent form. (iii) A lender may rely on any certification or documentation submitted by an applicant for a PPP loan or an eligible recipient or eligible entity that (A) is submitted pursuant to all applicable statutory requirements, regulations, and guidance related to a PPP loan, including under sections 7(a)(36) or (37) of the Small Business Act (15 U.S.C.

636(a)(36) and (37)). And (B) attests that the applicant, eligible recipient, or eligible entity, as applicable, has accurately provided the certification or documentation to the lender in accordance with the statutory requirements, regulations, and guidance related to PPP loans. With respect to a lender that relies on such a certification or documentation related to a Second Draw PPP Loan, an enforcement action may not be taken against the lender, and the lender shall not be subject to any penalties relating to loan origination or forgiveness of the Second Draw PPP Loan, if—(A) the lender acts in good faith relating to loan origination or forgiveness of the Second Draw PPP Loan based on that reliance. And (B) all other relevant Federal, State, local, and other statutory and regulatory requirements applicable to the lender are satisfied with respect to the Second Draw PPP Loan.

(3) SBA will pay lenders fees for processing Second Draw PPP Loans in the following amounts:Start Printed Page 3722 (i) for a Second Draw PPP Loan of up to (and including) $50,000, in an amount equal to the lesser of. (A) 50 percent of the balance of the financing outstanding at the time of disbursement of the loan. Or (B) $2,500. And (ii) for a Second Draw PPP Loan of more than $50,000, in an amount that is.

(A) 5 percent of the balance of the financing outstanding at the time of disbursement of the loan for a loan up to (and including) $350,000. And (B) 3 percent of the balance of the financing outstanding at the time of disbursement of the loan for a loan above $350,000. (i) Will an applicant's Second Draw PPP Loan application be affected if there are unresolved issues regarding the applicant's First Draw PPP Loan?. (1) If a First Draw PPP Loan is under review pursuant to PPP rules and/or information in SBA's possession indicates that the borrower may have been ineligible for the First Draw PPP Loan it received or for the loan amount received by the borrower, the lender will receive notification from SBA when the lender submits an application for guaranty of a Second Draw PPP Loan (“unresolved borrower”).

(2) If the lender receives notification that the Applicant for a Second Draw PPP Loan is an unresolved borrower, the lender will not receive an SBA loan number. SBA will resolve the issue related to the unresolved borrower expeditiously and will notify the lender of the process to obtain an SBA loan number for the Second Draw PPP Loan, if appropriate. (j) Are Second Draw PPP Loans eligible for loan forgiveness?. Second Draw PPP Loans are eligible for loan forgiveness on the same terms and conditions as First Draw PPP Loans, except that Second Draw PPP Loan borrowers with a principal amount of $150,000 or less are required to provide documentation of revenue reduction if such documentation was not provided at the time of the loan application as specified in subsections (g)(2)(iv) and (v) of this section.

V. Additional Information SBA may provide further guidance, if needed, through SBA notices and a program guide which will be posted on SBA's website at www.sba.gov. Questions on the Paycheck Protection Program 7(a) Loans (First Draw PPP Loans and Second Draw PPP Loans) may be directed to the Lender Relations Specialist in the local SBA Field Office. The local SBA Field Office may be found at https://www.sba.gov/​tools/​local-assistance/​districtoffices.

Compliance With Executive Orders 12866, 12988, 13132, 13563, and 13771, the Paperwork Reduction Act (44 U.S.C. Ch. 35), and the Regulatory Flexibility Act (5 U.S.C. 601-612) Executive Orders 12866, 13563, and 13771 This interim final rule is economically significant for the purposes of Executive Orders 12866 and 13563, and the Office of Management and Budget's Office of Information and Regulatory Affairs (OIRA) had determined that this is a major rule under the Congressional Review Act (5 U.S.C.

804(2)). SBA, however, is proceeding under the emergency provision at Executive Order 12866 section 6(a)(3)(D) based on the need to move expeditiously to mitigate the current economic conditions arising from the buy antibiotics emergency. This rule's designation under Executive Order 13771 will be informed by public comment. This rule is necessary to implement the Economic Aid Act in order to provide economic relief to small businesses nationwide adversely impacted under the buy antibiotics Emergency Declaration.

We anticipate that this rule will result in substantial benefits to small businesses, their employees, and the communities they serve. However, we lack data to estimate the effects of this rule. The Administrator of OIRA has determined that this is a major rule for purposes of the Congressional Review Act (5 U.S.C. 801 et seq.) (CRA).

Under section 801(3) of the CRA, a major rule takes effect 60 days after the rule is published in the Federal Register. Notwithstanding this requirement, section 808(2) of the CRA allows agencies to dispense with the requirements of section 801 when the agency for good cause finds that such procedure would be impracticable, unnecessary, or contrary to the public interest and the rule shall take effect at such time as the agency promulgating the rule determines. Pursuant to section 808(2) of the CRA, SBA finds, for good cause, that a 60-day delay in the effective date is unnecessary and contrary to the public interest. As discussed elsewhere in this interim final rule, the last day to apply for and receive a PPP loan is March 31, 2021.

Given the short duration of this program, and the urgent need to issue loans quickly, the Administrator in consultation with the Secretary has determined that it is impractical and not in the public interest to provide a delayed effective date. An immediate effective date will give small businesses the maximum amount of time to apply for loans and lenders the maximum amount of time to process applications before the program ends. Executive Order 12988 SBA has drafted this rule, to the extent practicable, in accordance with the standards set forth in section 3(a) and 3(b)(2) of Executive Order 12988, to minimize litigation, eliminate ambiguity, and reduce burden. The rule has no preemptive or retroactive effect.

Executive Order 13132 SBA has determined that this rule will not have substantial direct effects on the States, on the relationship between the National Government and the States, or on the distribution of power and responsibilities among the various layers of government. Therefore, SBA has determined that this rule has no federalism implications warranting preparation of a federalism assessment. Paperwork Reduction Act, 44 U.S.C. Chapter 35 SBA has determined that this rule will impose new recordkeeping or reporting requirements under the Paperwork Reduction Act (“PRA”).

This information collection (IC) consists of SBA Form 2483-SD (Paycheck Protection Program Second Draw Application Form) and SBA Form 2484-SD (Paycheck Protection Program Lender's Application—Second Draw Loan Guaranty. SBA has requested emergency approval for the IC required to implement the Second Draw PPP Program described above. Regulatory Flexibility Act (RFA) The Regulatory Flexibility Act (RFA) generally requires that when an agency issues a proposed rule, or a final rule pursuant to section 553(b) of the APA or another law, the agency must prepare a regulatory flexibility analysis that meets the requirements of the RFA and publish such analysis in the Federal Register. 5 U.S.C.

603, 604. Specifically, the RFA normally requires agencies to describe the impact of a rulemaking on small entities by providing a regulatory impact analysis. Such analysis must address the consideration of regulatory options that would lessen the economic effect of the rule on small entities. The RFA defines a “small entity” as (1) a proprietary firm meeting the size standards of the Small Business Administration (SBA).

(2) a nonprofit organization that is not dominant in its field. Or (3) a small government Start Printed Page 3723jurisdiction with a population of less than 50,000. 5 U.S.C. 601(3)-(6).

Except for small government jurisdictions with a population of less than 50,000, neither State nor local governments are “small entities.” The requirement to conduct a regulatory impact analysis does not apply if the head of the agency “certifies that the rule will not, if promulgated, have a significant economic impact on a substantial number of small entities.” 5 U.S.C. 605(b). The agency must, however, publish the certification in the Federal Register at the time of publication of the rule, “along with a statement providing the factual basis for such certification.” If the agency head has not waived the requirements for a regulatory flexibility analysis in accordance with the RFA's waiver provision, and no other RFA exception applies, the agency must prepare the regulatory flexibility analysis and publish it in the Federal Register at the time of promulgation or, if the rule is promulgated in response to an emergency that makes timely compliance impracticable, within 180 days of publication of the final rule. 5 U.S.C.

604(a), 608(b). Rules that are exempt from notice and comment are also exempt from the RFA requirements, including conducting a regulatory flexibility analysis, when among other things the agency for good cause finds that notice and public procedure are impracticable, unnecessary, or contrary to the public interest. Small Business Administration's Office of Advocacy guide. How to Comply with the Regulatory Flexibility Ac.

Ch.1. P.9. Since this rule is exempt from notice and comment, SBA is not required to conduct a regulatory flexibility analysis. Start Authority 15 U.S.C.

636(a)(36). antibiotics Aid, Relief, and Economic Security Act, Pub. L. 116-136, section 1114.

And Economic Aid to Hard-Hit Small Businesses, Nonprofits, and Venues Act, Pub. L. 116-260, section 303. End Authority Start Signature Jovita Carranza, Administrator.

End Signature End Supplemental Information [FR Doc. 2021-00452 Filed 1-12-21. 4:15 pm]BILLING CODE 8026-03-P.

Page updated: 01.06.2010 21:00