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: (If an incentive will be used, state what incentive will be offered and justify proposed incentives 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-depth 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 list the item number(s) for questions used from the question bank.
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 | 2021-01-25 |