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pdfForm Approved
OMB No. 0920-0904
Exp. Date 11/30/2014
(affix label here)
Patient ID
Number
Site
Sub-site
Sequential ID
SEARCH CES-D
Please answer the following questions about how you felt or behaved in the past week. If your
answers suggest the need for treatment and you are under 18 years old, this will need to be
shared with your parent or guardian.
Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining 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 CDC Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333; ATTN: PRA (0920-0904).
SEARCH 3 Cohort Study - CES-D 11-01-10
Page 1 of 4
The following questions ask you about how you felt or behaved in the past week. Please read each
question and shade in the best answer in the appropriate circle. Remember, there are no right or
wrong answers.
The response categories are:
Rarely or none of the time (less than once per week)
Some or a little of the time (1 - 2 days per week)
Occasionally or a moderate amount of the time (3 - 4 days per week)
Most or all of the time (5 - 7 days per week)
1. I was bothered by things that usually don’t bother me……......
2. I did not feel like eating: my appetite was poor……..….............
Rarely
Some
Occasionally
Rarely
Some
Occasionally
3. I felt that I could not shake off the blues even with the help of
family and friends……..…..…..…..…..…..…..….......................
Rarely
Some
Occasionally
4. I felt that I was just as good as other people……..…..…..........
Rarely
Some
Occasionally
Rarely
Some
Occasionally
Rarely
Some
Occasionally
Rarely
Some
Occasionally
Rarely
Some
Occasionally
Rarely
Some
Occasionally
Rarely
Some
Occasionally
5. I had trouble keeping my mind on what I was doing……..….....
6. I felt depressed……..…..…..…..…..…..…..…..…..…..….........
7. I felt that everything I did was an effort……..…..…..…............
8. I felt hopeful about the future……..….…..…..…..…...…..........
9. I thought my life had been a failure……..…..…..…..….............
10. I felt fearful……..…..…..…..…..…..…..…..…..…..…..….........
SEARCH 3 Cohort Study - CES-D 11-01-10
Most
Most
Most
Most
Most
Most
Most
Most
Most
Most
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The response categories are:
Rarely or none of the time (less than once per week)
Some or a little of the time (1 - 2 days per week)
Occasionally or a moderate amount of the time (3 - 4 days per week)
Most or all of the time (5 - 7 days per week)
11. My sleep was restless……..…..…..………..…..…..….................
12. I was happy……..…..…..…..…..…..…..…..…..…..…..............
13. I talked less than usual……..…..…..…..…..…..…..…..….........
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
14. I felt lonely……..…..…..…..…..…..…..…..…..….…...…..........
Rarely
Some
Occasionally
Most
15. People were unfriendly……..…..…..….…..…..…..…...….........
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
16. I enjoyed life……..…..…..…..…..…..…..…..…..…..….............
17. I had crying spells……..…..…..…..….…..…..…..…...…...........
18. I felt sad……..…..…..…..…..…..…..….…..…..…..…...............
19. I felt that people disliked me……..…..…..…..…..…..…............
20. I could not get going……..…..…..…..….…..…...…..…............
Rarely
Some
Occasionally
Most
Rarely
Some
Occasionally
Most
This is the end of the questionnaire. Thank you for answering these questions.
SEARCH 3 Cohort Study - CES-D 11-01-10
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FOR STUDY USE ONLY
Date Completed
Month
Day
Year
Date Reviewed
Reviewer Code
Month
Day
Year
Date Entered
Month
SEARCH 3 Cohort Study - CES-D 11-01-10
Day
Year
Data Entry
Code
Page 4 of 4
| File Type | application/pdf |
| Author | Susan Vestal |
| File Modified | 2013-01-29 |
| File Created | 2013-01-29 |