Attach B-2

Attachment B-2. Sample questionnaire to be pretested through Generic Questionnaire Clearance

(Cancer Quality of Life: Satisfaction with Participation in Social Roles – PROMIS Short Form: DRAFT)

OMB#0925-XXXX

EXP:xx/xxxx 

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Public reporting burden for this collection of information is estimated to average 2 minutes per response, including

the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and

completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is

not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Send comments regarding this burden estimate or any other aspect of this collection of information, including

Suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda,

MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

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Satisfaction with Participation in Social Roles – Short Form 1

Please respond to each item by marking one box per row.

Not at A little Some Quite a Very

All bit what bit much