Information Collection

Medical Outcomes Study Short Form

IC 183872 under ICR 200802-0920-009 · OMB 0920-0788.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form No number Medical Outcomes Study Short Form	Form
No number Medical Outcomes Study Short Form Attachment 22 Medical Outcomes Study Short Form 36.pdf	Form
Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc Medical Outcomes Study Short Form - Coverpage	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	No number	Medical Outcomes Study Short Form	Attachment 22 Medical Outcomes Study Short Form 36.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemiologic Studies and Surveillance of Disease Problems

FR Citation: 57 FR 62812

Number of Respondents: 246

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	246	246
Annual IC Time Burden (Hours)	82	82
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Medical Outcomes Study Short Form - Coverpage	Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc	12/19/2007

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.