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USPSTF New Topic Form

Use this form for nominating new preventive service topics that have not been reviewed by the UPSTF. If you want to
recommend reconsideration of an existing recommendation, please use the Topic Reconsideration Form.

Before submitting a new topic for nomination, please check that the topic is not:

Already covered in an active USPSTF recommendation
(Select http://www.uspreventiveservicestaskforce.org/uspstopics.htm.)
Already covered in a USPSTF recommendation under development
(Select http://www.uspreventiveservicestaskforce.org/uspstf/topicsprog.htm".)

Please complete this form and select "Submit." You will receive an automatic message to confirm your submission.
We regret that the USPSTF cannot respond to each individual topic submission.

Caution: Please be aware that you need to complete each nomination you make in one computer session. It is not possible
for comments to be saved and reopened.

Your Name and Affiliation (Optional):

Name: Affiliation:

May we contact you about this nomination? Yes

If "yes," please provide: Phone: Or, email:

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New Preventive Service Topic You Are Nominating (Required):

Rationale for the Topic (Required):

Category of Topic: Is this service screening, counseling, or preventive medications?

Primary Care Relevance: The preventive service must be provided in the primary care setting or referable from a primary care
setting. Is this service provided in the primary care setting or referable from a primary care setting?

Public Health Importance: Please describe the public health importance of the topic. Include burden of disease and suffering
and the potential of preventive service to reduce that burden. (Approx. 500 words)

Potential Impact: Please describe the potential impact of USPSTF's review of the topic, for example, expected changes in
clinical practice. (Approx. 100 words)

Supporting Documentation (Required):

Please list the evidence that supports your topic nomination. Specific citations will allow the USPSTF to give fullest
consideration to the details of your nomination. (All nominations will be fully considered.)

Documentation must be research published in peer-reviewed journals. Please note that the USPSTF does not evaluate
cost-effectiveness studies of preventive services in developing its recommendations.

Please list full citation(s) here and include a link to the article or its abstract.

When you have finished filling out this form, select “Submit” below. You will receive an automatic message to confirm
your submission. We regret that the USPSTF cannot respond to each individual topic submission.

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