Att 3 - Health Message Testing System Expedited Review Form

Attachment 3: Health Message Testing System Expedited Review Form

Health Message Testing System Expedited Review Form

1. Title of Study: (Please append screener and questionnaire)

______________________________________________________________________________

2. Study Population: (Discuss study population and explain how they will be selected/recruited.)

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

Respondent characteristics:

Number of subjects: _______________________

Number of males: _________________________

Number of females: _______________________

Age range: _______________________________

Racial/ethnic composition: __________________

Special group status: (e.g., risk group, health care providers, etc.)

Type of group/s: ________________________________

______________________________________________

Geographic location/s: _________________________________

3. Incentives: (State what incentive will be offered and justify proposed incentive to be used in study.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Study method: (Please check one below)

Central location intercept interview: _____

Telephone interview: _____ (CATI used: yes or no) _____

Individual in-dept interview (cognitive interview): _____

Focus group: _____

Online interview: _____

Other: (describe) _________________________________

5. Purpose of the overall communication effort into which this health message/s will fit: (Please provide 2-3 sentences below.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Category of time sensitivity: (Please check one below)

Health emergency: _____

Time-limited congressional/administrative mandate: _____

Press coverage correction: _____

Time-limited audience access: _____

Ineffective existing materials due to historical event/social trends: _____

Trend tracking: _____

7. Describe nature of time sensitivity: (Please provide 2-3 sentences below.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

8. Number of burden hours requested: __________

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

9. Are you using questions from the approved question bank? If yes, please identify the number of the questions used. If using questions that are not in the question bank, please list the item numbers and provide a brief rationale for adding these questions.

Yes: _____

No: _____

*** Items Below to be completed by Office of Associate Director for Communication (OADC)***

1. Number of burden hours remaining in current year’s allocation: _______

2. OADC confirmation of time-sensitivity:

Yes: _____

No: _____

_____________________________________

Project Officer Signature