| Heading and notes: | Form No. Q 152. Standard Interim period heading. | 
| Message area: | 30 unnumbered boxes in six lines. | 
| Reverse side: | Blank. | 
| Colours (text & form): | Black on white. | 
| Size of form overall: | 165 (?) × 202 mm. | 
| Size of datestamp box: | 24 × 24 mm. | 
|  | QI-TO-4: Unused transmission form. | 
Details of use and rarity.
| Form sub-number | Schedule number | Earliest recorded date | Rarity rating | 
| QI-TO-4 | Form No. Q 152. | Unknown used. | RRR |