21 Well Being

ID NUMBER:

FORM CODE: WBE VERSION: A 5/17/07

Contact Occasion

SEQ #

OMB#: 0925-XXXX

Exp. XX/XXXX

Public reporting burden for this collection of information is estimated to average 04 minutes 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). Do not return the completed form to this address.

H

OMB#: 0925-XXXX

Exp. XX/XXXX

CHS/SOL Well-Being Questionnaire

ID NUMBER:

FORM CODE: WBE VERSION: A 5/17/07

Contact Occasion

SEQ #

Acrostic:

Administrative Information

0a. Completion Date: // 0b. Staff ID:

Instructions: Mark the appropriate box for the response. Unless instructed, mark ONLY one response.

A. CES-D 10

Below is a list of some of the ways you may have felt or behaved. Please indicate how often you have felt this way during the past week. (Mark only one on each line)

Rarely or Some or Occasionally

none of a little of or a moderate All of

the time the time amount of time the time

(<1 day) (1-2 days) (3-4 days) (5-7 days)

1. I was bothered by things that usually

don’t bother me. 0 1 2 3

2. I had trouble keeping my mind on what

I was doing. 0 1 2 3

3. I felt depressed. 0 1 2 3

4. I felt that everything I did was an effort. 0 1 2 3

5. I felt hopeful about the future. 0 1 2 3

6. I felt fearful. 0 1 2 3

7. My sleep was restless. 0 1 2 3

8. I was happy. 0 1 2 3

9. I felt lonely. 0 1 2 3

10. I could not “get going”. 0 1 2 3

B. Spielberger Trait Anxiety Scale

Choose the appropriate response for each statement that indicates how you generally feel. Do not spend too much time on any one statement but give the answer which seems to describe how you generally feel.

Almost Almost

never Sometimes Often always

11. I feel nervous and restless. 0 1 2 3

12. I feel satisfied with myself. 0 1 2 3

13. I wish I could be as happy as

others seem to be. 0 1 2 3

14. I feel like a failure. 0 1 2 3

15. I worry too much over something 0 1 2 3

that really doesn’t matter.

16. I lack self-confidence. 0 1 2 3

17. I feel secure. 0 1 2 3

18. I feel inadequate. 0 1 2 3

19. I am a steady person. 0 1 2 3

20. I get in a state of tension or turmoil 0 1 2 3

as I think over my recent concerns

and interests.

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