HMTS 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 survey items or focus group guide)

______________________________________________________________________________

2. 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. Purpose of study: (Please check one below)

Trend tracking: _____

Concept testing: _____

Message testing: _____

Channel preference testing: _____

Exposure confirmation: _____

Other: (describe) ________________________________________

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. IRB approval or exemption ruling: (Please check one below)

Yes: _____

No: ______

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: _____

8. Describe nature of time sensitivity:

(Please provide 2-3 sentences below.)

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

9. Number of burden hours requested: __________

*** Items Below to be Completed by National Center for Health Marketing,

Division of Health Communication and Marketing***

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

2. NCHM Division of Health Communication and Marketing confirmation of time-sensitivity:

Yes: _____

No: _____

_____________________________________

Project Officer Signature