OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study

ICR 200802-0920-009 · OMB 0920-0788 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form No number Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentation) Form and Instruction New Repair queued
Form No number Social Support Questionnaire Form New Available
Form No number Ways of Coping Questionnaire Form New Available
Form No number Illness Management Questionnaire Form New Repair queued
Form No number Ironson-Woods Spirituality / Religiousness Index Form and Instruction New Available
Form No number Davidson Trauma Scale Form New Available
Form No number Illness Perception Questionnaire Form New Available
Form No number Zung Self-Rating Depression Scale Form New Available
Form No number Multi-dimensional Fatigue Inventory Form New Repair queued
Form No number Medical Outcomes Study Short Form Form New Repair queued
Form No number Symptoms Inventory Form New Repair queued
Form No number Adolescent Health Questionnaire Form New Available
Form No number Adolescent Subject Fatigue Questionnaire Form New Repair queued
Form No number Life Experiences Survey Form New Available
Form No number Traumatic Life Events Questionnaire Form New Repair queued
Form No number Childhood Trauma Questionnaire Form New Repair queued
Form No number Personality Diagnostic Questionnaire Form New Available
Form No number Spielberger State-Trait Anxiety Inventory Form New Repair queued
Form No number Economic Impact Form New Source copy available
Form No number Health Care Utilization (for parent of adolescent) Form New Repair queued
Form No number Health Care Utilization/Sense of Community (for adult) Form New Repair queued
Form No number CATI Detailed Telephone Interview Form New Available
Form No number Referral/Consent to Contact Form - Patient Form New Repair queued
Form No number Referral/Consent to Contact Form - Provider Form New Repair queued
Form No number Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (Post Intervention) Form and Instruction New Repair queued
Form No number Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention Form and Instruction New Repair queued
Form No number Health Care Provider Verification Form Form and Instruction New Repair queued
Followup CFS in GA - OMB Supporting Statement Rev 05-22-08.doc Supplementary Document Uploaded 2008-08-18 Repair queued
OMB Supporting Statement for Registry Redlined May 2008.doc Supplementary Document Uploaded 2008-08-18 Available
Attachment 22 Symptoms Inventory.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 20 Clinic Appointment letters for adults.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 19 Post clinical evaluation ineligibility letter.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 18-Hard to contact letter.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 17 Justification of Non exempted Clniical Questionnaires .doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 16 Psychiatric history - structured clinical interview for the DSM IV Scoring.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 15 Physical Exam Form.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 14. Two week medication usage history.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 13 12 hour urine collection instructions.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 12 Saliva specimen collection instructions.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 11b Adolescent gynecologic history form.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 10b Adolescent Medical History Form.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 10a Adult Medical history Form.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 8b Website content for general public.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 8a.1 Recruitment Letter for Adults.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 11a Adult gynecological history form.doc Supplementary Document Uploaded 2007-12-19 Available
2007 Registry Pilot 60-day notice.pdf Supplementary Document Uploaded 2007-12-18 Available
Attachment 2 Congressional Language 2003-2006.doc Supplementary Document Uploaded 2007-12-18 Repair queued
Attachment 1 Authorizing Legislation.doc Supplementary Document Uploaded 2007-12-18 Available
Attachment 24 Social Support Questionnaire OMB Cover page.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 24 Ways of Coping Questionnaire OMB cover page.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 23 Davidson Trauma Scale OMB Cover page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 24 Illness Perception Questionnaire OMB Cover sheet.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 23 Zung Self-Rating Depression Scale OMB cover page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 22 Multi-dimensional Fatigue Inventory OMB cover sheet.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 25 Life Experiences Survey for adults OMB Cover page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 25 Traumatic Life Events Questionnaire OMB Cover Page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 25 Childhood Trauma Questionniare for adults OMB cover page.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 23 Personality Diagnostic Questionnaire (PDQ4+) OMB cover page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 23 State Trait Anxiety Inventory for adults OMB cover page.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 6a Non-physician referral instructions.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 6a Physician Referral Instructions.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 6a Physician Referral Instructions.doc Supplementary Document Uploaded 2007-12-19 Available
Attachment 6a Non-physician referral instructions.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 5b Provider website Frequently Asked Questions.doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 5a.3. Frequently Asked Questions by Healthcare Providers .doc Supplementary Document Uploaded 2007-12-19 Repair queued
Attachment 5a.1.Provider recruitment letter.doc Supplementary Document Uploaded 2007-12-19 Repair queued
OMB Supporting Statement for Registry 4 120107.doc Supporting Statement A Uploaded 2008-01-31 Available
IC Document Collections
IC IDCollectionTypeStatusForm
183881 Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentation) Form and Instruction New
183880 Social Support Questionnaire Form New
183879 Ways of Coping Questionnaire Form New
183878 Illness Management Questionnaire Form New
183877 Ironson-Woods Spirituality / Religiousness Index Form and Instruction New
183876 Davidson Trauma Scale Form New
183875 Illness Perception Questionnaire Form New
183874 Zung Self-Rating Depression Scale Form New
183873 Multi-dimensional Fatigue Inventory Form New
183872 Medical Outcomes Study Short Form Form New
183871 Symptoms Inventory Form New
183870 Adolescent Health Questionnaire Form New
183869 Adolescent Subject Fatigue Questionnaire Form New
183868 Life Experiences Survey Form New
183867 Traumatic Life Events Questionnaire Form New
183866 Childhood Trauma Questionnaire Form New
183865 Personality Diagnostic Questionnaire Form New
183864 Spielberger State-Trait Anxiety Inventory Form New
183863 Economic Impact Form New
183862 Health Care Utilization (for parent of adolescent) Form New
183861 Health Care Utilization/Sense of Community (for adult) Form New
183860 CATI Detailed Telephone Interview Form New
183859 Referral/Consent to Contact Form - Patient Form New
183858 Referral/Consent to Contact Form - Provider Form New
183857 Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (Post Intervention) Form and Instruction New
183856 Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention Form and Instruction New
183855 Health Care Provider Verification Form Form and Instruction New
ICR Details
0920-0788 200802-0920-009
Historical Active
HHS/CDC
Registry of Unexplained Fatiguing Illnesses and Chronic Fatigue Syndrome (CFS): A Pilot Study
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 08/25/2008
Retrieve Notice of Action (NOA) 02/25/2008
Approved consistent with revisions reflecting the limitations of the sample frame.
  Inventory as of this Action Requested Previously Approved
08/31/2009 12 Months From Approved
7,152 0 0
2,077 0 0
0 0 0
CDC will recruit specific types of physicians and other health care providers who practice in Bibb County, GA and areas within 30 miles of Bibb County, to screen patients for eligibility in a registry of unexplained fatiguing illness. Eligible subjects will be invited to the CDC clinic in Macon, GA for a clinical evaluation.
US Code: 42 USC 241 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  72 FR 41758 07/31/2007
72 FR 73023 12/26/2007
No
27
IC Title Form No. Form Name
Health Care Utilization (for parent of adolescent) No number Health Services Utilization - Consent
CATI Detailed Telephone Interview No number CATI Detailed Telephone Interview
Health Care Utilization/Sense of Community (for adult) No number Health Services Utilization - Sense of Community Questionnaire
Economic Impact No number Economic Impact Questionnaire for Adults
Spielberger State-Trait Anxiety Inventory No number State-Trait Anxiety Inventory
Personality Diagnostic Questionnaire No number Personality Diagnostic Questionnaire
Childhood Trauma Questionnaire No number Childhood Trauma Questionnaire
Traumatic Life Events Questionnaire No number Traumatic Life Events Questionnaire
Life Experiences Survey No number Life Experiences Survey
Adolescent Subject Fatigue Questionnaire No number Adolescent Subject Fatigue Questionnaire
Adolescent Health Questionnaire No number Adolescent Health Questionnaire
Symptoms Inventory No number Symptoms Inventory
Medical Outcomes Study Short Form No number Medical Outcomes Study Short Form
Multi-dimensional Fatigue Inventory No number Multi-dimensional Fatigue Inventory
Illness Management Questionnaire No number Illness Management Questionnaire
Zung Self-Rating Depression Scale No number Zung Self-Rating Depression Scale
Illness Perception Questionnaire No number Illness Perception Questionnaire
Davidson Trauma Scale No number Davidson Trauma Scale
Ironson-Woods Spirituality / Religiousness Index No number Ironson-Woods Spirituality /Religiousness Index
Ways of Coping Questionnaire No number Ways of Coping Questionnaire
Social Support Questionnaire No number Social Support Questionnaire
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentation) No number Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (at CDC presentations)
Referral/Consent to Contact Form - Provider No number Referral/Consent to Contact Form - Provider
Referral/Consent to Contact Form - Patient No number Referral/Consent to Contact Form - Patient
Health Care Provider Verification Form No number Attachment 5 - Healthcare Provider Verification
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire - Pre-Intervention No number Provider Questionnaire - Pre-intervention
Health Care Provider Knowledge, Attitudes and Beliefs Questionnaire (Post Intervention) No number Provider Questionnaire - Post-intervention
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 7,152 0 0 7,152 0 0
Annual Time Burden (Hours) 2,077 0 0 2,077 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection.
$1,702,799
No
No
Uncollected
Uncollected
Uncollected
Uncollected
Maryam Daneshvar 4046394604
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/25/2008