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16
Questions
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1
ID#
Your ID# is your First Initial + Last 4 of SSN
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2
What program are you enrolled in?
Corporate College
College Degree & Certificate Programs
Adult Education
Center for Minority Excellence
Center for Minority Excellence
Corporate College
College Degree & Certificate Programs
Adult Education
Center for Minority Excellence
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3
Date of birth
Please enter your date of birth
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Date
Month
Day
Year
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4
Name
Please enter your name
First Name
Last Name
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5
Please enter your phone number or email (whichever is your preferred contact method)
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6
Over the last 2 weeks, how often have you been bothered by any of the following problems?
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7
Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly every day
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8
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
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9
Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
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10
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
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11
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
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12
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly every day
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13
Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly every day
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14
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
Not at all
Several days
More than half the days
Nearly every day
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15
Thoughts that you would be better off dead, or of hurting yourself
Not at all
Several days
More than half the days
Nearly every day
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16
If you checked off any problems, how difficult have these problems made it for you to do work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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