51 Pediatric Funtional Assessment of Chronic Illness Therap

Attachment 51
Pediatric Functional Assessment of Chronic Illness Therapy – Fatigue
(FACIT-F)

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

Pediatric Functional Assessment of Chronic Illness Therapy – Fatigue
(FACIT-F)
Estimated time burden: 2 minutes
FACIT-F – Children 8-17
[00-self-pF intro]

On the next screens, you will see questions about your tiredness., Read
each question carefully and answer as best you can. Please consider each
question by itself and choose an answer that honestly shows how you feel.
1

After you make your choice, the computer will automatically go on to the
next question. If you want to change your answer, click on the GO BACK
button to return to the previous question and then choose a different
answer.
Click on the CONTINUE button when you are ready to begin.

[01-self-pF1]

During the past 7 days, I feel tired.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[02-self-pF2]

During the past 7 days, I have energy (or strength).
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[03-self-pF3]

During the past 7 days, I could do my usual things at home.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[04-self-pF4]

During the past 7 days, I had trouble starting things because I was too
tired.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[05-self-pF5]

During the past 7 days, I had trouble finishing things because I was too
tired.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[06-self-pF6]

During the past 7 days, I needed to sleep during the day.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[07-self-pF7]

During the past 7 days, I got upset by being too tired to do things I wanted
to do.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[08-self-pF8]

During the past 7 days, Being tired made it hard for me to play or go out
with my friends as much as I'd like.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[09-self-pF9]

During the past 7 days, I needed help doing my usual things at home.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[10-self-pF10]

During the past 7 days, I feel weak.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX
[11-self-pF11]

During the past 7 days, I was too tired to eat.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[12-self-pF12]

During the past 7 days, Being tired made me sad.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[13-self-pF13]

During the past 7 days, Being tired made me mad (angry).
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

FACIT-F – Proxy Report for Children 8-17
[00-proxy pF1]

On the next screens, you will see questions about your child’s tiredness.
Read each question carefully and answer as best as you can. Please
consider each question by itself and choose an answer that you believe
honestly shows how your child’s feels and acts.
After you make your choice, the computer will automatically go on to the
next question. If you want to change your answer, click on the GO BACK
button to return to the previous question and then choose a different
answer. 2
Click on the CONTINUE button when you are ready to begin.
[proxy pF1]

During the past 7 days, My child feels tired. 3
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF2]

Public reporting burden for this collection of information is estimated to average 2 1/2 hours per response, including
the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions
for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD
20892-7974, ATTN: PRA (0925-xxxx*) EXP: (xx/xxxx). Do not return the completed form to this address.

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

During the past 7 days, My child has energy (or strength).
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF3]

During the past 7 days, My child could do his/her usual things at home.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF4]

During the past 7 days, My child had trouble starting things because s/he
was too tired.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF5]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

During the past 7 days, My child had trouble finishing things because s/he
was too tired.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF6]

During the past 7 days, My child needed to sleep during the day.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF7]

During the past 7 days, My child got upset by being too tired to do things
s/he wanted to do.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF8]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

During the past 7 days, Being tired made it hard for my child to play or go
out with my friends as much as s/he would like.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF9]

During the past 7 days, My child needed help doing his/her usual things at
home.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF10]

During the past 7 days, My child feels weak.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF11]

OMB: 0925-XXXX
Expiration Date: XX/XX/XXXX

During the past 7 days, My child was too tired to eat.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF12]

During the past 7 days, Being tired made my child sad.
None of the time
A little bit of time
Some of the time
Most of the time
All of the time

[proxy pF13]

During the past 7 days, Being tired made my child mad (angry).
None of the time
A little bit of time
Some of the time
Most of the time
All of the time