Form 0920 Fatigue Scale

Attachment D8

Fatigue Scale

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/20xx

Fatigue Scale

VI. Many people experience a sense of extreme or excessive tiredness during and at the end of the work day.

For each question, check the box that most accurately reflects how often you experience each aspect of fatigue.

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 (0920-XXXX).

		Everyday (1)	At least once a week (2)	At least once a month (3)	Less than once a month (4)	Never (5)
Physical fatigue involves extreme physical tiredness and an inability to engage in physical activity. During the PAST 6 MONTHS, how often did you…
1	Feel physically exhausted at the end of the workday?	□	□	□	□	□
2	Have difficulty engaging in physical activity at the end of the workday?	□	□	□	□	□
3	Feel physically worn out at the end of the workday?	□	□	□	□	□
4	Want to physically shut down at the end of the workday?	□	□	□	□	□
5	Feel physically drained at the end of the workday?	□	□	□	□	□
6	Want to avoid anything that took too much physical energy at the end of the workday?	□	□	□	□	□
Mental fatigue involves extreme mental tiredness and an inability to think or concentrate. During the PAST 6 MONTHS, how often did you…
7	Feel mentally exhausted at the end of the workday?	□	□	□	□	□
8	Have difficulty thinking and concentrating at the end of the workday?	□	□	□	□	□
9	Feel mentally worn out at the end of the workday?	□	□	□	□	□
10	Want to mentally shut down at the end of the workday?	□	□	□	□	□
11	Feel mentally drained at the end of the workday?	□	□	□	□	□
12	Want to avoid anything that took too much mental energy at the end of the workday?	□	□	□	□	□
Emotional fatigue involves extreme emotional tiredness and an inability to feel or show emotions. During the PAST 6 MONTHS, how often did you…
13	Feel emotionally exhausted at the end of the workday?	□	□	□	□	□
14	Have difficulty showing and dealing with emotions at the end of the workday?	□	□	□	□	□
15	Feel emotionally worn out at the end of the workday?	□	□	□	□	□
16	Want to emotionally shut down at the end of the workday?	□	□	□	□	□
17	Feel emotionally drained at the end of the workday?	□	□	□	□	□
18	Want to avoid anything that took too much emotional energy at the end of the workday?	□	□	□	□	□