Information Collection Request

[NCEZID] School-Based Active Surveillance (SBAS) of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Among Schoolchildren: Phase-2 of the National Roll-Out

ICR 202212-0920-001 · OMB 0920-1396 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0920-1396 can be found here:

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form 0920-22HN School District Feedback Form	Form and Instruction	New	Repair queued
Form 920-22HN Webinar 1 Feedback Form	Form and Instruction	New	Repair queued
Form 0920-22HN Question Guide for Face-to-Face Evaluation Interviews	Form and Instruction	New	Repair queued
Form 0920-22HN Site Baseline Survey	Form and Instruction	New	Repair queued
Form 0920-22HN Demographic Data Collection Points	Form and Instruction	New	Repair queued
Form 0920-22HN Electronic Platform Quarterly Chronic Absenteeism Data Reporting Form	Form and Instruction	New	Repair queued
2022-26886- 30DAY FRN PUBLISHED 12122022.pdf	Supplementary Document	Uploaded 2022-12-13	Repair queued
Attachment I_SBAS_Consent Form and Authorization for School District Representatives.docx	Supplementary Document	Uploaded 2022-12-01	Repair queued
Attachment J_SBAS_Consent Form and Authorization for School Nurses.docx	Supplementary Document	Uploaded 2022-12-01	Repair queued
Attachment H_SBAS_NASN IRB Exempt Determination Notice.pdf	Supplementary Document	Uploaded 2022-12-01	Repair queued
Attachment G_SBAS_Privacy Act Checklist Active Surveillance School Age Children.docx	Supplementary Document	Uploaded 2022-12-01	Repair queued
Supporting Statement B_SBAS.docx	Supporting Statement B	Uploaded 2022-12-01	Repair queued
Supporting Statement A_SBAS.docx	Supporting Statement A	Uploaded 2022-12-01	Repair queued

Information collection document groups
IC ID	Collection	Type	Status
257211	School District Feedback Form	Form and Instruction	New
257210	Webinar 1 Feedback Form	Form and Instruction	New
257209	Question Guide for Face-to-Face Evaluation Interviews	Form and Instruction	New
257208	Site Baseline Survey	Form and Instruction	New
257207	Demographic Data Collection Points	Form and Instruction	New
257206	Electronic Platform Quarterly Chronic Absenteeism Data Reporting Form	Form and Instruction	New

Record metadata
Status	Received in OIRA
Agency/Subagency	HHS/CDC
OMB Control No	0920-1396
Type of Information Collection	New collection (Request for a new OMB Control Number)
Agency Tracking No	0920-22HN
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31