North Carolina Department of Health and Human Services

Division of Public Health
Family Planning Media Review Documentation
County:	Date:
The Material
1.	Title:
2.	Major Topic Area:	3.	Publication Date:
4.	Type of Media	5.	Produced by:
DVD	Poster

Video ½”	Exhibit

Video ¾”	Brochure/Pamphlet

Slides	PSA (Public Service

Announcement)

Other:
6.	Cost:
7.	Length (minutes or pages):
8.	Where your Agency Obtained the Material:
Created in-house	Women’s and Children’s Health Mailroom
Other:
Your Evaluation
9.	Description. Give a one sentence description of the content.

10.	Audience. (check all that apply)
a. Male	Female	Either Gender
b. Age Groups:	General (all ages)

High School	Elementary

College Students	Middle School

Adults
c. Ethnic Group Focus:	African American

Caucasian	American Indian

Hispanic/Latino	Asian American

Multicultural
11.	Quality. (check all that apply)

Accuracy of Information

Technical Quality

Communicates Message Clearly

Appropriateness to Audience	Excellent

Good

Fair

Poor

12.	Comments on quality.
(Please turn the page to continue.) (

DHHS 3491 (Revised 10/11)
Family Planning and Reproductive Health Unit (Review 10/13)

13.	Reading Level. For written materials, what is the reading level?
How did you determine the reading level?	SMOG Method	FOG Method	Provided by the producer
Other:
14.	Disposition.	Approved	Disapproved
15.	Restrictions. If approved, describe any restrictions that should be placed on the material.

16.	Recommendations for Use:

Reviewed by:

Name

Address

Occupation

Gender/Age

Race*

Ethnic
Origin**

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

F- M-
Age

1- 2- 3-
4- 5- 6-

1- 2- 3-
4- 5- 6-

*Race: 1-American Indian or Alaska Native; 2-Asian; 3-Black/African American; 4-Native Hawaiian/Other Pacific Islander; 5-Unknown; 6-White

**Ethnic Origin: 1-Hispanic Cuban; 2-Hispanic Mexican American; 3-Hispanic Other; 4-Hispanic Puerto Rican; 5-Not Hispanic/Latino; 6-Unreported

18.	Signature of Person Completing Form: ____________________________________________________

INSTRUCTIONS

Purpose:	To document that a local committee representing the community has reviewed and approved all informational and educational materials used in a local family planning program. For questions related to Media Review, call 919-707-5695.

Preparation:	1.	Complete a separate form for each item reviewed.

2.	Each committee member may use a form to write her or his comments on. The chairperson may then transfer a summary of the member’s comments onto a separate form to send to the Family Planning and Reproductive Health Unit.

3.	The chairperson completes items 1-8 and 13 prior to review.

4.	The chairperson completes items 9-12 and 14-17 after the committee has reviewed the material and reached a consensus on the questions.

5	Each committee member signs and completes information in item 17.

6.	The chairperson signs item 18.

Distribution:	1.	Retain original in a media review file at the local health department.

2.	Send copy to:	N.C. DHHS

Family Planning and Reproductive Health Unit

1929 Mail Service Center

Raleigh, North Carolina 27699-1929

COURIER #56-23-01

Disposition:	You may destroy the form when the material reviewed is no longer available or in use.

Reorder:	Additional forms may be copied, or you may order them from:

N.C. DHHS, Family Planning and Reproductive Health Unit

1929 Mail Service Center

Raleigh, North Carolina 27699-1929

COURIER #56-23-01

DHHS 3491 (Revised 10/11)
Family Planning and Reproductive Health Unit (Review 10/13)

North Carolina Department of Health and Human Services

afarmer

2011-10-03

SCHS