| 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. |
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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 |