41 Additional Somatosensation Questions

Attachment 41
Additional Somatosensation Questions

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Additional Somatosensation Questions
Estimated time burden: 2 minutes
Adult and Children 13-17
[00 Somatosensation]

On the next screens, we will ask you questions about sensations and/or unusual
feelings that some people encounter. Consider each question by itself; then
choose or type in an answer that best shows your experience.
After you make your choice, click on the NEXT button to go on to the next
question. If you want to change your last answer, click on the GO BACK button
to return to the previous question and then choose or type in a different answer.
Click on the CONTINUE button when you are ready to begin.

1

[01 Somatosensation]

Have you ever experienced any of the following (check all that apply)?
Numbness or tingling in your hands
Numbness and tingling in your feet
Neuropathy
Psoriasis, eczema, or rash
None of these
Don’t know

Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[02 Somatosensation]

Have you ever received chemotherapy?
Yes
No
Don’t know

[03 Somatosensation]

Thinking about the past 12 months, how many hours a day do you stand on your
feet?
Less than one hour
One to four hours
Four to eight hours
More than eight hours a day
Don't know

[04 Somatosensation]

In the past 7 days, how often did you experience stinging pain?
Not sure if I had this type of pain
Never, did not have this type of pain
Rarely
Sometimes
Often
Always

[04a Somatosensation]

In the past 7 days, how intense was your stinging pain?
Mild

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Moderate
Severe
Very severe

[05 Somatosensory]

In the past 7 days, how often did you experience pricking pain?
Not sure if I had this type of pain
Never
Rarely
Sometimes
Often
Always

[05a Somatosensory]

In the past 7 days, how intense was your pricking pain?
Mild
Moderate
Severe
Very severe

[06 Somatosensory]

In the past 7 days, how often did you experience itchy pain?
Not sure if had this type of pain

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Never
Rarely
Sometimes
Often
Always

[06a Somatosensory]

In the past 7 days, how intense was your itchy pain?
Mild
Moderate
Severe
Very severe

[07 Somatosensation]

In the past 7 days, how often did you experience burning pain?
Not sure if I had this type of pain
Never
Rarely
Sometimes
Often
Always

[07a Somatosensation]

In the past 7 days, how intense was your burning pain?
Mild

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Moderate
Severe
Very severe

[08 Somatosensation]

In the past 7 days, how often did you experience aches and pains?
Not sure if I had aches and pains
Never
Rarely
Sometimes
Often
Always

[08a Somatosensation]

In the past 7 days, how intense were your aches and pains?
Mild
Moderate
Severe
Very severe

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[09 Somatosensation]

In the past 7 days, Did your pain feel itchy?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[10 Somatosensation]

In the past 7 days, Did your pain feel stinging?
Not at all
A little bit
Somewhat
Quite a bit
Very much

[11 Somatosensation]

In the past 7 days, Did your pain feel burning?
Not at all
A little bit
Somewhat
Quite a bit
Very much

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
Proxy Report for Children 3-17
Time burden – 1 minute
[00 Somatosensation(Proxy)]

On the next screens, we will ask you to answer questions about your child and
his/her experience with sensations and/or unusual feelings that some people
encounter. Consider each question by itself; then choose or type in an answer
that best shows your child’s experience.
After you make your choice, click on the NEXT button to go on to the next
question. If you want to change your last answer, click on the GO BACK button
to return to the previous question and then choose or type in a different answer.
Click on the CONTINUE button when you are ready to begin.
[01 Somatosensation(Proxy)]

Has your child ever experienced any of the following...(please check all that
apply)?
Numbness or tingling in his/her hands
Neuropathy
Psoriasis, eczema, or rash
None of these
I don’t know

02 Somatosensation(Proxy)]

Has your child ever received chemotherapy? 2
Yes
No
Rather not answer
I don't know

Public reporting burden for this collection of information is estimated to average 2 1/2 hours 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*) EXP: (xx/xxxx). Do not return the completed form to this address.