HMTS Request Template

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 subject:

Number of males:

Age range:

Number of females:

Racial/ethnic composition:
Special group status: (e.g., risk group, health care providers)
Type of group(s):
Geographic location(s):

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

Participants will receive $2.00 and the payment within 1 week of completing the survey. The amount is
based on a number of variables for this project, including the total participation time and specifications
that each participant has to meet to participate in the study. Participants are part of the panel and they have
accounts where the money accumulates and is then redeemable through their award program or could be
cashed out.

4. Study method: (Please check one below)
Central location intercept interview:
Online Interview:
Telephone interview:
Other (describe):

Focus group:
Individual in-depth interview (cognitive interview):

(CATI used: yes or no):

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

The Emergency Management, Radiation, and Chemical Branch (EMRCB) provides basic information on
radiation and its health effects as well as emergency instructions for individuals and families. To help
ensure the quality of these messages and graphics, CDC wishes to test them with the public to gather
information to ensure they are clear, useful, and will help the public understand their health risks in the
event of emergency.
6. Category of time sensitivity: (Please check one below)
Health emergency:
Time-limited audience access:
Press coverage correction:
Time-limited congressional/administrative mandate:
Trend Tracking
Ineffective existing materials due to historical event/social trends:
7. Describe nature of time sensitivity: (Please provide 2-3 sentences below.)

8. Number of burden hours requested:

BURDEN HOURS
No. of
Participation
Respondents Time

Category of Respondent

Burden

Totals
9. Are you using questions from the approved question bank?

Yes

If yes, please list the item number(s) for questions used from the question bank separated by a comma.
(e.g., 1a, 3c, 130d)
1b, 2a ,4a, 8a, 12a, 14a, 33e, 37d, 55e, 60e, 63e, 65e, 66e, 74e

*** Items below to be completed by Office of Associate Director for Communication (OADC)***
1. Number of burden hours remaining in current year's allocation: 3368
2. OADC confirmation of time-sensitivity:
Yes:
No:

Dawn B. Griffin
Project Officer
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