Rapid Message Testing & Development System Expedited Review Form

Attachment 8:

Rapid Message Testing & Development 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.)

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

3. 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: ____________________________

4. Incentives

(If an incentive will be used, state what incentive will be offered and justify proposed incentives to be used in study.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Study method

(Please check one below.)

Individual in-depth interview: _____

Focus group: _____

Online survey: _____

Other: (describe) ___________________________

6. Purpose of the overall communication effort into which this health message/s will fit

(Please provide 2-3 sentences below.)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. 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: _____

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8. Describe nature of time sensitivity

(Please provide 2-3 sentences below.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

9. Number of burden hours requested: __________

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Totals

10. Are you using questions from the approved question bank? If yes, please list the item number(s) for questions used from the question bank.

Yes: _____

No: _____