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 |
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Totals |
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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
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Attachment 3: Health Message Testing System Expedited Review Form |
Author | Angela Ryan |
File Modified | 0000-00-00 |
File Created | 2021-01-31 |