Home Monitoring for Early Detection of Chronic Disease Exacerbation (COPD)

Home Monitoring for Early Detection of
Chronic Disease Exacerbation.
OMB No. 2900-0770

Estimated Burden: 5 minutes
Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you
are not required to respond to, a collection of information unless it displays a valid OMB number. We
anticipate that the time expended by all individuals who complete this survey will average 5
minutes. This includes the time it will take to follow instructions, gather the necessary facts and
respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA
services as well as customer expectations and desires. The results of this telephone/mail survey will
lead to improvements in the quality of service delivery by helping to achieve improved services.
Participation in this survey is voluntary and failure to respond will have no impact on benefits to which
you may be entitled.

1

PATIENT HEALTH QUESTIONNAIRE 8 (PHQ-8)

Over the last 2 weeks, how often have you been
bothered by any of the following problems?

Not at all Several
days

More
Nearly
than half every day
the days

1. Little interest or pleasure in doing things

0

1

2

3

2. Feeling down, depressed, or hopeless

0

1

2

3

3. Trouble falling or staying asleep, or sleeping too
much

0

1

2

3

4.

Feeling tired or having little energy

0

1

2

3

5.

Poor appetite or overeating

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

6. Feeling bad about yourself — or that you are a
failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading
the newspaper or watching television
8. Moving or speaking so slowly that other people
could have noticed? Or the opposite — being so
fidgety or restless that you have been moving
around a lot more than usual

Total=__________

Questions or comments concerning the accuracy of the burden estimate and any suggestions for
reducing this burden should be sent to Rene Hearns, VA Northeast Ohio Healthcare System at
216-791-2300 x45835.