Information Collection

Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren

IC 243850 under ICR 201912-0920-003 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren	Form
Attachment E -School Surveillance GenIC--Question Guide for Face to Face Evaluation Interviews.docx	Other-Question Guide
Electronic Platform Chronic Absenteeism Reporting Form Attachment A -School Surveillance GenIC--Electronic Platform Quarterly Chronic Absenteeism Data Reporting Form.docx	Form
Demographic Data Collection Points Attachment B - School Surveillance GenIC-- Demographic Data Collection Points.docx	Form
Pilot Site Baseline Survey Attachment C -School Surveillance GenIC-- Pilot Site Baseline Survey.docx	Form
Webinar Feedback Form Attachment D-School Surveillance GenIC-- Webinar 1 Feedback Form.docx	Form
School District Feedback Form Attachment F -School Surveillance GenIC--School District Feedback Form.docx	Form
Supporting Statement A Active Surveillance School Age Children Pilot rev_08.19.20_clean.docx Supporting Statement A	IC Document
Supporting Statement B Active Surveillance School Age Children Pilot rev_08.19.20_clean.docx Supporting Statement B	IC Document
GenIC Request Template for Active Surveillance of School Age Children Pilot.docx Request for Approval	IC Document
Attachment H -School Surveillance GenIC--IRB Protocol Approval with Modifications.pdf IRB Approval	IC Document
Attachment I -School Surveillance GenIC--Consent Form and Authorization for School District Representatives.docx Consent - School district representatives	IC Document
Attachment J -School Surveillance GenIC--Consent Form and Authorization for School Nurses.docx Consent - School nurses	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Formative Research to Support Active Surveillance of Myalgic Encelphalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren

Agency IC Tracking Number:

0920-1154-20OB

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	School District Feedback Form	Attachment F -School Surveillance GenIC--School District Feedback Form.docx	Yes	Yes	Fillable Fileable
Form	none	Electronic Platform Chronic Absenteeism Reporting Form	Attachment A -School Surveillance GenIC--Electronic Platform Quarterly Chronic Absenteeism Data Reporting Form.docx	Yes	Yes	Fillable Fileable
Form	none	Demographic Data Collection Points	Attachment B - School Surveillance GenIC-- Demographic Data Collection Points.docx	Yes	Yes	Fillable Fileable
Form	none	Pilot Site Baseline Survey	Attachment C -School Surveillance GenIC-- Pilot Site Baseline Survey.docx	Yes	Yes	Fillable Fileable
Form	none	Webinar Feedback Form	Attachment D-School Surveillance GenIC-- Webinar 1 Feedback Form.docx	Yes	Yes	Fillable Fileable
Other-Question Guide			Attachment E -School Surveillance GenIC--Question Guide for Face to Face Evaluation Interviews.docx	Yes	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 88 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	116	116
Annual IC Time Burden (Hours)	228	228
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Supporting Statement A Active Surveillance School Age Children Pilot rev_08.19.20_clean.docx	10/01/2020
Supporting Statement B	Supporting Statement B Active Surveillance School Age Children Pilot rev_08.19.20_clean.docx	10/01/2020
Request for Approval	GenIC Request Template for Active Surveillance of School Age Children Pilot.docx	10/01/2020
IRB Approval	Attachment H -School Surveillance GenIC--IRB Protocol Approval with Modifications.pdf	10/01/2020
Consent - School district representatives	Attachment I -School Surveillance GenIC--Consent Form and Authorization for School District Representatives.docx	10/01/2020
Consent - School nurses	Attachment J -School Surveillance GenIC--Consent Form and Authorization for School Nurses.docx	10/01/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.