Form 0920- Centers for Epidemiological Studies Depression

Attachment D4

Center for Epidemiological Studies Depression

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Center for Epidemiological Studies Depression

II. Below is a list of the ways you might have felt or behaved. Please indicate how often you have felt this way for the PAST WEEK by marking an “X” in the appropriate box.

1 = Rarely or none of the time (less than 1 day)

2 = Some or a little of the time (1-2 days)

3 = Occasionally or a moderate amount of time (3-4 days)

4 = Most or all of the time (5-7 days)

Public reporting burden of this collection of information is estimated to average 2 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 CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (XXXX).

	During the PAST WEEK:	<1 day (1)	1-2 days (2)	3-4 days (3)	5-7 days (4)
1	I was bothered by things that usually don’t bother me.	□	□	□	□
2	I did not feel like eating; my appetite was poor.	□	□	□	□
3	I felt that I could not shake off the blues even with help from my family or friends.	□	□	□	□
4	I felt that I was just as good as other people.	□	□	□	□
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.	□	□	□	□
11	My sleep was restless	□	□	□	□
12	I was happy	□	□	□	□
13	I talked less than usual.	□	□	□	□
14	I felt lonely	□	□	□	□
15	People were unfriendly	□	□	□	□
16	I enjoyed life.	□	□	□	□
17	I had crying spells	□	□	□	□
18	I felt sad.	□	□	□	□
19	I felt that people dislike me.	□	□	□	□
20	I could not get “going”.	□	□	□	□