Screener

Form Approved

OMB Control No.: 0920-1154

Expiration date: 01/31/2023

Health Education and Health Promotion in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Knowledge, Attitudes and Beliefs in the U.S. General Public

SCREENER

1. What is your age? Enter number in years.

____ years old RANGE 1-100; TERMINATE IF <18

2. Are you currently living in the United States?

1. Yes

2. No TERMINATE

3. I describe myself as…

RANDOMIZE

1. Male

2. Female

3. Transgender: ______ OPEN SPECIFY, ANCHOR

4. Which of the following conditions have you heard of before today? Please select all that apply.

RANDOMIZE

1. Arthritis

2. Asthma

3. Cardiovascular diseases (e.g., heart attack, myocardial infarction, angina, chronic heart disease, stroke)

4. Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)

5. Chronic Obstructive Pulmonary Disease (COPD)

6. Diabetes

7. Kidney disease

8. Lyme disease

9. None of the above EXCLUSIVE, ANCHOR

[PROGRAMMING/CODING: IF S4≠4 OR S4=9 CODE AS “NEVER HEARD OF ME/CFS” AND SKIP TO DEMOGRAPHIC SECTION]

5. You mentioned that you had heard of Chronic Fatigue Syndrome or Myalgic Encephalomyelitis. For the remainder of the survey we will refer to Myalgic Encephalomyelitis/Chronic Fatigue Syndrome simply as ME/CFS.

Public reporting burden of this collection of information is estimated to average 1 minute 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 0920-1154

[PROGRAMMING: Insert hover definition over “ME/CFS” as “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome” starting from this point in the survey]

Which of the following statements about ME/CFS best describes you? Please select all that apply.

1. I have been diagnosed with ME/CFS by a doctor CANNOT SELECT WITH 2 [CODE AS “DIAGNOSED”]

2. I think I may have ME/CFS, but have not been diagnosed by a doctor CANNOT SELECT WITH 1 [CODE AS “SYMPTOMATIC”]

3. I am the primary caregiver of someone who has been diagnosed with ME/CFS [CODE AS “CAREGIVER”]

4. I have friends, relatives, or co-workers who have been diagnosed with ME/CFS

5. None of the above EXCLUSIVE

3