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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.

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Information Collection (IC) Details

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Multi-site Clinical Assessment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (MCAM)ATT.3 0920-20QS
 
Yes New
 
Voluntary
 

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

Health Illness Prevention

 

2,423 0
   
Individuals or Households
 
   0 %

  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

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