OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Multi-site Clinical Assessment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (MCAM)ATT.3

IC 248111 under ICR 202106-0920-021 · OMB 0920-1341.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 0920-20QS
Multi-site Clinical Assessment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (MCAM)ATT.3		 Form and Instruction
0920-20QS 1_CDC Symptom Inventory (CDC-SI)_Form A
1_CDC Symptom Inventory (CDC-SI)_Form A.pdf 		Form and Instruction
0920-20QS 1_CDC Symptom Inventory (CDC-SI)_Form A
1_CDC Symptom Inventory (CDC-SI)_Form A.pdf 		Form and Instruction
0920-20QS 2_CDC Symptom Inventory (CDC-SI)_Form B
2_CDC Symptom Inventory (CDC-SI)_Form B.pdf 		Form and Instruction
0920-20QS 2_CDC Symptom Inventory (CDC-SI)_Form B
2_CDC Symptom Inventory (CDC-SI)_Form B.pdf 		Form and Instruction
0920-20QS 3_CDC Symptom Inventory (CDC-SI)
3_CDC Symptom Inventory (CDC-SI).pdf 		Form and Instruction
0920-20QS 3_CDC Symptom Inventory (CDC-SI)
3_CDC Symptom Inventory (CDC-SI).pdf 		Form and Instruction
0920-20QS 4_Short Form CDC-SI_Checklist
4_Short Form CDC-SI_Checklist.pdf 		Form and Instruction
0920-20QS 4_Short Form CDC-SI_Checklist
4_Short Form CDC-SI_Checklist.pdf 		Form and Instruction
0920-20QS 5_Medical Outcomes Study Short Form 36
5_Medical Outcomes Study Short Form 36.pdf 		Form and Instruction
0920-20QS 5_Medical Outcomes Study Short Form 36
5_Medical Outcomes Study Short Form 36.pdf 		Form and Instruction
0920-20QS 6_Multidimensional Fatigue Inventory_MFI-20
6_Multidimensional Fatigue Inventory_MFI-20.pdf 		Form and Instruction
0920-20QS 6_Multidimensional Fatigue Inventory_MFI-20
6_Multidimensional Fatigue Inventory_MFI-20.pdf 		Form and Instruction
0920-20QS 7_DePaul Symptom Questionnaire_DSQ
7_DePaul Symptom Questionnaire_DSQ.pdf 		Form and Instruction
0920-20QS 7_DePaul Symptom Questionnaire_DSQ
7_DePaul Symptom Questionnaire_DSQ.pdf 		Form and Instruction
0920-20QS 8_DSQ_26 selected questions
8_DSQ_26 selected questions.pdf 		Form and Instruction
0920-20QS 8_DSQ_26 selected questions
8_DSQ_26 selected questions.pdf 		Form and Instruction
0920-20QS 9_DSQ_18 selected questions
9_DSQ_18 selected questions.pdf 		Form and Instruction
0920-20QS 9_DSQ_18 selected questions
9_DSQ_18 selected questions.pdf 		Form and Instruction
0920-20QS 10_PROMIS Short Forms&Sleep
10_PROMIS Short Forms&Sleep.pdf 		Form and Instruction
0920-20QS 10_PROMIS Short Forms&Sleep
10_PROMIS Short Forms&Sleep.pdf 		Form and Instruction
0920-20QS 11_PROMIS SF - Fatigue_SD_SRI_PB_PI
11_PROMIS SF - Fatigue_SD_SRI_PB_PI.pdf 		Form and Instruction
0920-20QS 11_PROMIS SF - Fatigue_SD_SRI_PB_PI
11_PROMIS SF - Fatigue_SD_SRI_PB_PI.pdf 		Form and Instruction
0920-20QS 12_Brief Pain Inventory_BPI.pdf
12_Brief Pain Inventory_BPI.pdf 		Form and Instruction
0920-20QS 12_Brief Pain Inventory_BPI.pdf
12_Brief Pain Inventory_BPI.pdf 		Form and Instruction
0920-20QS 13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL
13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL.pdf 		Form and Instruction
0920-20QS 13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL
13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL.pdf 		Form and Instruction
0920-20QS 14_CDC HRQoL-4
14_CDC HRQoL-4.pdf 		Form and Instruction
0920-20QS 14_CDC HRQoL-4
14_CDC HRQoL-4.pdf 		Form and Instruction
0920-20QS 15_CDC HRQoL-4 with activity limitation questions
15_CDC HRQoL-4 with activity limitation questions.pdf 		Form and Instruction
0920-20QS 15_CDC HRQoL-4 with activity limitation questions
15_CDC HRQoL-4 with activity limitation questions.pdf 		Form and Instruction
0920-20QS 16_Self-Rating Depression Scale_SDS
16_Self-Rating Depression Scale_SDS.pdf 		Form and Instruction
0920-20QS 16_Self-Rating Depression Scale_SDS
16_Self-Rating Depression Scale_SDS.pdf 		Form and Instruction
0920-20QS 17_Illness Impact Questionnaire
17_Illness Impact Questionnaire.pdf 		Form and Instruction
0920-20QS 17_Illness Impact Questionnaire
17_Illness Impact Questionnaire.pdf 		Form and Instruction
0920-20QS 18_Saliva Data Collection Sheet
18_Saliva Data Collection Sheet.pdf 		Form and Instruction
0920-20QS 18_Saliva Data Collection Sheet
18_Saliva Data Collection Sheet.pdf 		Form and Instruction
0920-20QS 19_Orthostatic Grading Scale_OGS
19_Orthostatic Grading Scale_OGS.pdf 		Form and Instruction
0920-20QS 19_Orthostatic Grading Scale_OGS
19_Orthostatic Grading Scale_OGS.pdf 		Form and Instruction
0920-20QS 20_COMPosite Autonomic Symptom Score 31_COMPASS-31
20_COMPosite Autonomic Symptom Score 31_COMPASS-31.pdf 		Form and Instruction
0920-20QS 20_COMPosite Autonomic Symptom Score 31_COMPASS-31
20_COMPosite Autonomic Symptom Score 31_COMPASS-31.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
Form and Instruction 0920-20QS 1_CDC Symptom Inventory (CDC-SI)_Form A 1_CDC Symptom Inventory (CDC-SI)_Form A.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 2_CDC Symptom Inventory (CDC-SI)_Form B 2_CDC Symptom Inventory (CDC-SI)_Form B.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 3_CDC Symptom Inventory (CDC-SI) 3_CDC Symptom Inventory (CDC-SI).pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 4_Short Form CDC-SI_Checklist 4_Short Form CDC-SI_Checklist.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 5_Medical Outcomes Study Short Form 36 5_Medical Outcomes Study Short Form 36.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 6_Multidimensional Fatigue Inventory_MFI-20 6_Multidimensional Fatigue Inventory_MFI-20.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 7_DePaul Symptom Questionnaire_DSQ 7_DePaul Symptom Questionnaire_DSQ.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 8_DSQ_26 selected questions 8_DSQ_26 selected questions.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 9_DSQ_18 selected questions 9_DSQ_18 selected questions.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 10_PROMIS Short Forms&Sleep 10_PROMIS Short Forms&Sleep.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 11_PROMIS SF - Fatigue_SD_SRI_PB_PI 11_PROMIS SF - Fatigue_SD_SRI_PB_PI.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 12_Brief Pain Inventory_BPI.pdf 12_Brief Pain Inventory_BPI.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL 13_Patient Health Questionnaire_PHQ-8_GAD-7_HRQoL.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 14_CDC HRQoL-4 14_CDC HRQoL-4.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 15_CDC HRQoL-4 with activity limitation questions 15_CDC HRQoL-4 with activity limitation questions.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 16_Self-Rating Depression Scale_SDS 16_Self-Rating Depression Scale_SDS.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 17_Illness Impact Questionnaire 17_Illness Impact Questionnaire.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 18_Saliva Data Collection Sheet 18_Saliva Data Collection Sheet.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 19_Orthostatic Grading Scale_OGS 19_Orthostatic Grading Scale_OGS.pdf Yes Yes Fillable Fileable
Form and Instruction 0920-20QS 20_COMPosite Autonomic Symptom Score 31_COMPASS-31 20_COMPosite Autonomic Symptom Score 31_COMPASS-31.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 2,423 0 0 0 2,423 0
Annual IC Time Burden (Hours) 359 0 0 0 359 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.