Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form No number Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentations)	Form and Instruction	New	Repair queued
Form No number Social Support Questionnaire	Form	New	Available
Form No number Ways of Coping Questionnaire	Form	New	Available
Form No number Illness Management Questionnaire	Form	New	Available
Form No number Ironson-Woods Spirituality /Religiousness Index	Form and Instruction	New	Available
Form No number Davidson Trauma Scale	Form	New	Available
Form No number Illness Perception Questionnaire	Form	New	Available
Form No number Zung Self-Rating Depression Scale	Form	New	Available
Form No number Multi-dimensional Fatigue Inventory	Form	New	Available
Form No number Medical Outcomes Study Short Form	Form	New	Available
Form No number Symptoms Inventory	Form	New	Available
Form No number Adolescent Health Questionnaire	Form	New	Available
Form No number Adolescent Subject Fatigue Questionnaire	Form	New	Available
Form No number Life Experiences Survey	Form	New	Available
Form No number Traumatic Life Events Questionnaire	Form	New	Available
Form No number Childhood Trauma Questionnaire	Form	New	Available
Form No number Personality Diagnostic Questionnaire	Form	New	Available
Form No number State-Trait Anxiety Inventory	Form	New	Available
Form No number Economic Impact Questionnaire for Adults	Form	New	Source copy available
Form No number Health Services Utilization - Consent	Form	New	Available
Form No number Health Services Utilization - Sense of Community Questionnaire	Form	New	Repair queued
Form No number CATI Detailed Telephone Interview	Form	New	Available
Form No number Referral/Consent to Contact Form - Patient	Form	New	Available
Form No number Referral/Consent to Contact Form - Provider	Form	New	Available
Form No number Provider Questionnaire - Post-intervention	Form and Instruction	New	Repair queued
Form No number Provider Questionnaire - Pre-intervention	Form and Instruction	New	Available
Form No number Attachment 5 - Healthcare Provider Verification	Form and Instruction	New	Available
Followup CFS in GA - OMB Supporting Statement Rev 05-22-08.doc	Supplementary Document	Uploaded 2008-08-18	Repair queued
OMB Supporting Statement for Registry Redlined May 2008.doc	Supplementary Document	Uploaded 2008-08-18	Available
Attachment 22 Symptoms Inventory.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 20 Clinic Appointment letters for adults.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 19 Post clinical evaluation ineligibility letter.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 18-Hard to contact letter.doc	Supplementary Document	Uploaded 2007-12-19	Repair queued
Attachment 17 Justification of Non exempted Clniical Questionnaires .doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 16 Psychiatric history - structured clinical interview for the DSM IV Scoring.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 15 Physical Exam Form.doc	Supplementary Document	Uploaded 2007-12-19	Repair queued
Attachment 14. Two week medication usage history.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 13 12 hour urine collection instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 12 Saliva specimen collection instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 11b Adolescent gynecologic history form.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 10b Adolescent Medical History Form.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 10a Adult Medical history Form.doc	Supplementary Document	Uploaded 2007-12-19	Repair queued
Attachment 8b Website content for general public.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 8a.1 Recruitment Letter for Adults.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 11a Adult gynecological history form.doc	Supplementary Document	Uploaded 2007-12-19	Available
2007 Registry Pilot 60-day notice.pdf	Supplementary Document	Uploaded 2007-12-18	Available
Attachment 2 Congressional Language 2003-2006.doc	Supplementary Document	Uploaded 2007-12-18	Available
Attachment 1 Authorizing Legislation.doc	Supplementary Document	Uploaded 2007-12-18	Available
Attachment 24 Social Support Questionnaire OMB Cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 24 Ways of Coping Questionnaire OMB cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 23 Davidson Trauma Scale OMB Cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 24 Illness Perception Questionnaire OMB Cover sheet.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 23 Zung Self-Rating Depression Scale OMB cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 25 Life Experiences Survey for adults OMB Cover page.doc	Supplementary Document	Uploaded 2007-12-19	Repair queued
Attachment 25 Traumatic Life Events Questionnaire OMB Cover Page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 25 Childhood Trauma Questionniare for adults OMB cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 23 Personality Diagnostic Questionnaire (PDQ4+) OMB cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 23 State Trait Anxiety Inventory for adults OMB cover page.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 6a Non-physician referral instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 6a Physician Referral Instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 6a Physician Referral Instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 6a Non-physician referral instructions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 5b Provider website Frequently Asked Questions.doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 5a.3. Frequently Asked Questions by Healthcare Providers .doc	Supplementary Document	Uploaded 2007-12-19	Available
Attachment 5a.1.Provider recruitment letter.doc	Supplementary Document	Uploaded 2007-12-19	Available
OMB Supporting Statement for Registry 4 120107.doc	Supporting Statement A	Uploaded 2008-01-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183881	Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentation)	Form and Instruction	New	Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentations)
183880	Social Support Questionnaire	Form	New	Social Support Questionnaire
183879	Ways of Coping Questionnaire	Form	New	Ways of Coping Questionnaire
183878	Illness Management Questionnaire	Form	New	Illness Management Questionnaire
183877	Ironson-Woods Spirituality / Religiousness Index	Form and Instruction	New	Ironson-Woods Spirituality /Religiousness Index
183876	Davidson Trauma Scale	Form	New	Davidson Trauma Scale
183875	Illness Perception Questionnaire	Form	New	Illness Perception Questionnaire
183874	Zung Self-Rating Depression Scale	Form	New	Zung Self-Rating Depression Scale
183873	Multi-dimensional Fatigue Inventory	Form	New	Multi-dimensional Fatigue Inventory
183872	Medical Outcomes Study Short Form	Form	New	Medical Outcomes Study Short Form
183871	Symptoms Inventory	Form	New	Symptoms Inventory
183870	Adolescent Health Questionnaire	Form	New	Adolescent Health Questionnaire
183869	Adolescent Subject Fatigue Questionnaire	Form	New	Adolescent Subject Fatigue Questionnaire
183868	Life Experiences Survey	Form	New	Life Experiences Survey
183867	Traumatic Life Events Questionnaire	Form	New	Traumatic Life Events Questionnaire
183866	Childhood Trauma Questionnaire	Form	New	Childhood Trauma Questionnaire
183865	Personality Diagnostic Questionnaire	Form	New	Personality Diagnostic Questionnaire
183864	Spielberger State-Trait Anxiety Inventory	Form	New	State-Trait Anxiety Inventory
183863	Economic Impact	Form	New	Economic Impact Questionnaire for Adults
183862	Health Care Utilization (for parent of adolescent)	Form	New	Health Services Utilization - Consent
183861	Health Care Utilization/Sense of Community (for adult)	Form	New	Health Services Utilization - Sense of Community Questionnaire
183860	CATI Detailed Telephone Interview	Form	New	CATI Detailed Telephone Interview
183859	Referral/Consent to Contact Form - Patient	Form	New	Referral/Consent to Contact Form - Patient
183858	Referral/Consent to Contact Form - Provider	Form	New	Referral/Consent to Contact Form - Provider
183857	Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (Post Intervention)	Form and Instruction	New	Provider Questionnaire - Post-intervention
183856	Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention	Form and Instruction	New	Provider Questionnaire - Pre-intervention
183855	Health Care Provider Verification Form	Form and Instruction	New	Attachment 5 - Healthcare Provider Verification

ICR Details

OMB Control No: 0920-0788	ICR Reference No: 200802-0920-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/25/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/25/2008
Terms of Clearance: Approved consistent with revisions reflecting the limitations of the sample frame.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2009	12 Months From Approved
Responses	7,152	0	0
Time Burden (Hours)	2,077	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: CDC will recruit specific types of physicians and other health care providers who practice in Bibb County, GA and areas within 30 miles of Bibb County, to screen patients for eligibility in a registry of unexplained fatiguing illness. Eligible subjects will be invited to the CDC clinic in Macon, GA for a clinical evaluation.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: Public Health Service Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 41758	07/31/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 73023	12/26/2007
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 27

table that charts list of burden

IC Title	Form No.	Form Name
Adolescent Health Questionnaire	No number	Adolescent Health Questionnaire
Adolescent Subject Fatigue Questionnaire	No number	Adolescent Subject Fatigue Questionnaire
CATI Detailed Telephone Interview	No number	CATI Detailed Telephone Interview
Childhood Trauma Questionnaire	No number	Childhood Trauma Questionnaire
Davidson Trauma Scale	No number	Davidson Trauma Scale
Economic Impact	No number	Economic Impact Questionnaire for Adults
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (Post Intervention)	No number	Provider Questionnaire - Post-intervention
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentation)	No number	Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentations)
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention	No number	Provider Questionnaire - Pre-intervention
Health Care Provider Verification Form	No number	Attachment 5 - Healthcare Provider Verification
Health Care Utilization (for parent of adolescent)	No number	Health Services Utilization - Consent
Health Care Utilization/Sense of Community (for adult)	No number	Health Services Utilization - Sense of Community Questionnaire
Illness Management Questionnaire	No number	Illness Management Questionnaire
Illness Perception Questionnaire	No number	Illness Perception Questionnaire
Ironson-Woods Spirituality / Religiousness Index	No number	Ironson-Woods Spirituality /Religiousness Index
Life Experiences Survey	No number	Life Experiences Survey
Medical Outcomes Study Short Form	No number	Medical Outcomes Study Short Form
Multi-dimensional Fatigue Inventory	No number	Multi-dimensional Fatigue Inventory
Personality Diagnostic Questionnaire	No number	Personality Diagnostic Questionnaire
Referral/Consent to Contact Form - Patient	No number	Referral/Consent to Contact Form - Patient
Referral/Consent to Contact Form - Provider	No number	Referral/Consent to Contact Form - Provider
Social Support Questionnaire	No number	Social Support Questionnaire
Spielberger State-Trait Anxiety Inventory	No number	State-Trait Anxiety Inventory
Symptoms Inventory	No number	Symptoms Inventory
Traumatic Life Events Questionnaire	No number	Traumatic Life Events Questionnaire
Ways of Coping Questionnaire	No number	Ways of Coping Questionnaire
Zung Self-Rating Depression Scale	No number	Zung Self-Rating Depression Scale

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	7,152	0	0	7,152	0	0
Annual Time Burden (Hours)	2,077	0	0	2,077	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $1,702,799

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/25/2008

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