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

IC Title:

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

Agency IC Tracking Number:

0920-20QS

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,423

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	2,423	2,423
Annual IC Time Burden (Hours)	359	359
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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