MECFS HP - Screener

Form Approved

OMB Control No. 0920-1071

Exp. Date: 06/30/2018

Day of Interview: ____________________________

Date of Interview: ____________________________

Time of Interview: _______________________ (all EST)

Number to call day of study: _______________________

(What is it – cell, home or work)

Name: _____________________________________________

Cell number: _________________________________________

Work number: ________________________________________

Home number: ________________________________________

Other number: ________________________________________

Address where to mail the check:

___________________ ________________________________

City: ________________________State: ___________Zip: ______

Email address: __________________________________________

Email address: __________________________________________

Hello, my name is from DYNAMIC RESEARCH. I’m calling you regarding formative research in the area of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (ME/CFS).

We are seeking to speak to Physicians/PA/NP’s such as yourself nationwide.

Please let me stress that this is being done only for formative research purposes and all the information that you give us will be kept strictly confidential. We are seeking only your opinion. There is no right or wrong.

The study is being done via phone and can be done on a day and time that is convenient for you.

We are doing this in partnership with Synergy America Inc, and they are a subcontractor for the Centers for Disease Control and Prevention.

We would offer an honorarium of $20.00 to you for your time and consideration.

I’d like to ask you some questions, which will only take a few minutes of your time.

Screener

Sex: Male____ Female_____

Year of Birth: ______

Which title best describes you?

Family Practice

General Practice

Internal Medicine

Physician Assistant

Nurse Practitioner

How many years have you been in practice? ___________

Are you board certified? __________

How many physicians are in your practice: ____________

How many PA’s: ________

How many NP’s: ________

On a weekly basis, how many patients do you see: ___________

Have you ever given a diagnosis of ME/CFS: _____________

Do you treat patients with ME/CFS: _________

Definition below if needed

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a complex, multifaceted disorder characterized by extreme fatigue and a host of other symptoms that can worsen after physical or mental activity, but do not improve with rest.

Public reporting burden of this collection of information is estimated to take 5 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-1071.