Information Collection

Multi-site Clinical Assessment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (MCAM)ATT.5

IC 248257 under ICR 202106-0920-021 · OMB 0920-1341.

Documents and Forms

Document Name Document Type
Form 0920-20QS Multi-site Clinical Assessment of Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome (MCAM)ATT.5 Form and Instruction
0920-20QS 1_Visual Analogue Scale for CFS Symptoms 1_Visual Analogue Scale for CFS Symptoms.pdf Form and Instruction
0920-20QS 1_Visual Analogue Scale for CFS Symptoms 1_Visual Analogue Scale for CFS Symptoms.pdf Form and Instruction
0920-20QS 2_EQ-5D-Y Health Questionnaire 2_EQ-5D-Y Health Questionnaire.pdf Form and Instruction
0920-20QS 2_EQ-5D-Y Health Questionnaire 2_EQ-5D-Y Health Questionnaire.pdf Form and Instruction
0920-20QS 3_PROMIS SFv1 Physical Function 3_PROMIS SFv1 Physical Function.pdf Form and Instruction
0920-20QS 3_PROMIS SFv1 Physical Function 3_PROMIS SFv1 Physical Function.pdf Form and Instruction
0920-20QS 4_Physical Fitness and Exercise Activity Levels of Scale 4_Physical Fitness and Exercise Activity Levels of Scale.pdf Form and Instruction
0920-20QS 4_Physical Fitness and Exercise Activity Levels of Scale 4_Physical Fitness and Exercise Activity Levels of Scale.pdf Form and Instruction
0920-20QS 5_International Physical Activity Questionnaire_Self-Adm 5_International Physical Activity Questionnaire_Self-Administered Long Form.pdf Form and Instruction
0920-20QS 5_International Physical Activity Questionnaire_Self-Adm 5_International Physical Activity Questionnaire_Self-Administered Long Form.pdf Form and Instruction
0920-20QS 6_Physical Activity Readiness Questionnaire_PAR-Q 6_Physical Activity Readiness Questionnaire_PAR-Q.pdf Form and Instruction
0920-20QS 6_Physical Activity Readiness Questionnaire_PAR-Q 6_Physical Activity Readiness Questionnaire_PAR-Q.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.5	Agency IC Tracking Number:	0920-20QS

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-20QS	1_Visual Analogue Scale for CFS Symptoms	1_Visual Analogue Scale for CFS Symptoms.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	2_EQ-5D-Y Health Questionnaire	2_EQ-5D-Y Health Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	3_PROMIS SFv1 Physical Function	3_PROMIS SFv1 Physical Function.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	4_Physical Fitness and Exercise Activity Levels of Scale	4_Physical Fitness and Exercise Activity Levels of Scale.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	5_International Physical Activity Questionnaire_Self-Administered Long Form	5_International Physical Activity Questionnaire_Self-Administered Long Form.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	0920-20QS	6_Physical Activity Readiness Questionnaire_PAR-Q	6_Physical Activity Readiness Questionnaire_PAR-Q.pdf	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: 294	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	294	294
Annual IC Time Burden (Hours)	291	291
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.