EDUCATIONAL/PROMOTIONAL MATERIALS REVIEW FORM

 
 

This form must accompany newly developed/reprinted educational/promotional Materials sent to your Network Program Manager for review.  Please check off the appropriate box for each question. 
 

Date:   Contract Number: 

Agency Name: 

Contact Person:   Telephone Number: 

      Fax #: 

      Email:  
 

1. Title of Material: 

 
 

2. Type of Material:

 
 

☐ Brochure/Pamphlet

☐ Curriculum

☐ Fact Sheet

☐ Newspaper article

☐ Locally-developed NERI

☐ Other (specify):   
 
 

☐ Newsletter

☐ Poster/Flyer

☐ Draft Script

☐ Video, including pre-approved script

☐ Website 
 
 

3. Language: ☐ English ☐ Spanish ☐ Other: 

 
 

4. Goal and Objective of your SOW that this material addresses:  Goal , Objective

 
 

5. How will this material be used?

 
 

☐ Background information/research

☐ Staff training

☐ Other (specify):  

☐ Professional Resource

☐ Consumer education 
 
 
 

6. Consumer target audience(s):  describe, including age, ethnicity, gender:

 
 
 

7. Was this material developed using research-based theory or model?

☐  Yes    What theory/model: 

☐  No (explain):   
 

8. Was this material pilot tested with the target audience you are trying to reach?

☐  Yes, describe pilot:   

☐  No (explain):   
 

9. How will you evaluate the effectiveness of this material?