OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Parent Proxies (baseline only + retest)

IC 197920 under ICR 201105-0925-006 · OMB 0925-0638.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Attach 30 Instructions for Emotional Health Questionnaire.pdf Instruction
7 Pain Assessment Ages 3-7
Attach 7 Pain Asssessment Proxy Ages 3-7.pdf 		Form and Instruction
8 Pain Assessment Ages 8-12
Attach 8 Pain Assessment Ages 8-12.pdf 		Form and Instruction
9 Pain Assessment Ages 8-12
Attach 9 Pain Assessment Ages 13-17.pdf 		Form and Instruction
31 Emotional Health Questionaire
Attach 31 Emotional Health Questionnaires for Toolbox.xlsx 		Form and Instruction
32 Supplemental Emotional Health Questionaire
Attach 32 Supplemental Emotional Health Questionnaires.xls 		Form and Instruction
41 Additional Somatosensation Questions
Attach 41 Additional Somatosensation Questions.pdf 		Form and Instruction
42 Additional Audition Olfaction Taste
Attach 42 Additional Audition Olfaction Taste Questions.pdf 		Form and Instruction
27 Handedness Assessment
Attach 27 Determining Handedness.pdf 		Form and Instruction
43 Cognition Information Form
Attach 43 Cognition Information Form.pdf 		Form and Instruction
44 Health Care Access and Utilization
Attach 44 Health Care Access and Utilization.pdf 		Form and Instruction
48 Pediatric Perceived Cognitive Proxy
Attach 48 Pediatric Perceived Cognitive Function (PCF) - Proxy.pdf 		Form and Instruction
51 Pediatric Funtional Assessment of Chronic Illness Therap
Attach 51 Pediatric Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F).pdf 		Form and Instruction
53 School Performance and Activities
Attach 53 School Performance and Activities.pdf 		Form and Instruction
54 Socio-demographic form
Attach 54 Sociodemographic Form- Parent.pdf 		Form and Instruction
59 Education Proxy Report for Children
Attach 59 Education Proxy Report for Children.pdf 		Form and Instruction
40 Initial Child/Proxy Questionaire
Attach 40 Initial Questionnaire-Proxy and Child.pdf 		Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

layout table

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
Instruction Attach 30 Instructions for Emotional Health Questionnaire.pdf Yes Yes Paper Only
Form and Instruction 31 Emotional Health Questionaire Attach 31 Emotional Health Questionnaires for Toolbox.xlsx Yes Yes Fillable Fileable
Form and Instruction 32 Supplemental Emotional Health Questionaire Attach 32 Supplemental Emotional Health Questionnaires.xls Yes Yes Fillable Fileable
Form and Instruction 41 Additional Somatosensation Questions Attach 41 Additional Somatosensation Questions.pdf Yes Yes Fillable Fileable
Form and Instruction 42 Additional Audition Olfaction Taste Attach 42 Additional Audition Olfaction Taste Questions.pdf Yes Yes Fillable Fileable
Form and Instruction 27 Handedness Assessment Attach 27 Determining Handedness.pdf Yes Yes Fillable Fileable
Form and Instruction 43 Cognition Information Form Attach 43 Cognition Information Form.pdf Yes Yes Fillable Fileable
Form and Instruction 44 Health Care Access and Utilization Attach 44 Health Care Access and Utilization.pdf Yes Yes Fillable Fileable
Form and Instruction 48 Pediatric Perceived Cognitive Proxy Attach 48 Pediatric Perceived Cognitive Function (PCF) - Proxy.pdf Yes Yes Fillable Fileable
Form and Instruction 51 Pediatric Funtional Assessment of Chronic Illness Therapy Fatigue Attach 51 Pediatric Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F).pdf Yes Yes Fillable Fileable
Form and Instruction 53 School Performance and Activities Attach 53 School Performance and Activities.pdf Yes Yes Fillable Fileable
Form and Instruction 54 Socio-demographic form Attach 54 Sociodemographic Form- Parent.pdf Yes Yes Fillable Fileable
Form and Instruction 59 Education Proxy Report for Children Attach 59 Education Proxy Report for Children.pdf Yes Yes Fillable Fileable
Form and Instruction 40 Initial Child/Proxy Questionaire Attach 40 Initial Questionnaire-Proxy and Child.pdf Yes Yes Fillable Fileable
Form and Instruction 7 Pain Assessment Ages 3-7 Attach 7 Pain Asssessment Proxy Ages 3-7.pdf Yes Yes Fillable Printable
Form and Instruction 8 Pain Assessment Ages 8-12 Attach 8 Pain Assessment Ages 8-12.pdf Yes Yes Fillable Fileable
Form and Instruction 9 Pain Assessment Ages 8-12 Attach 9 Pain Assessment Ages 13-17.pdf Yes Yes Fillable Fileable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 6,750 0 6,750 0 0 0
Annual IC Time Burden (Hours) 3,375 0 3,375 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
No associated records found
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.