Mental Health Issues Among Deployed Personnel: Longitudinal Assessment of the Resilience of Deployed Sailors and Marines - Follow-up
Mental Health Issues Among Deployed Personnel: Longitudinal Assessment of the Resilience of Deployed Sailors and Marines - Follow-up
Resilience-FollowUp-Survey
Mental Health Issues Among Deployed Personnel: Longitudinal Assessment of the Resilience of Deployed Sailors and Marines - Follow-up
OMB: 0703-0056
OMB Clearance No.: RCS # OPNAV 6500-1 (DON)
OMB Clearance Expiration Date: Expiration: 6/31/2008
STATUS OF TRANSITIONING MILITARY PERSONNEL FOLLOW-UP SURVEY |
INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE
All questions on this survey provide a set of possible answers. Please read all the answers before marking your choice. If none of the printed answers exactly applies to you, place an "X" on the square for the one answer that best fits your situation.
Use only the pencil you were given. Erase cleanly any answer you wish to change.
Put an "X" on the center of the square to indicate your answer. Don't use other marks.
x
●
If you are asked to give numbers or write letters in boxes, please enter your responses as shown below. Please enter ONE number or letter to a box.
Telephone number
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For many questions, you should place an "X" in only one square for your answer in the column below the question. However, some questions ask you to mark all the choices that apply. When asked to “mark all that apply,” please do so as shown here:
EXAMPLE: Have you ever had any of the following conditions? (Mark all that apply.)
Back pain
Ringing in the ears
Difficulty remembering
Trouble sleeping
Chronic headaches
Skin rashes
Difficulty breathing
PRIVACY ACT STATEMENT
Authority. 5 U.S.C. 301
Purpose. Medical research information will be collected in an experimental research project #NHRC.2007.0011, titled Status of Transitioning Military Personnel, to enhance basic medical knowledge, or to develop tests, procedures, and equipment to improve the diagnosis, treatment, or prevention of illness, injury, or performance impairment.
Routine Uses. Medical research information will be used for analysis and reports by the Departments of the Navy and Defense, and other U.S. Government agencies, provided this use is compatible with the purpose for which the information was collected. Use of the information may be granted to non‑Government agencies or individuals by the Navy Surgeon General following the provisions of the Freedom of Information Act or as may be indicated in the accompanying Informed Consent Form.
Disclosure. Provision of information is voluntary. There are no penalties for not providing the requested information but failure to provide the requested information may result in failure to be accepted as a research volunteer in an experiment, or in removal from the program.
P
LEASE
GO TO PAGE 2.
Are you currently on Active Duty status?
1 Yes
STOP, thank you for taking time to consider
this survey. Please return this entire questionnaire as instructed
in the information you received.
2 No
CONTINUE TO QUESTION 2.
Are you currently serving in the National Guard or Reserve?
1 Yes
2 No
What was your official date of separation from the military?
-
/
/
D
D
M
M
Y
Y
Y
Y
What is your marital status?
1 Married
2 Living as married (living with fiancé, boyfriend or girlfriend but not married)
3 Separated and not living as married
4 Divorced and not living as married
5 Widowed and not living as married
6 Single, never married, and not living as married
How many dependent children do you have?
1 1 child
2 2 children
3 3 or more children
4 I don’t have any children
Are you currently . . .?
-
(Place an "X" on each line)
Yes
No
a. Working full-time (work 35 or more hours per week on average)
1
2
b. Working part-time (work less than 35 hours per week on average)
1
2
c. Working as self-employed in own business or profession
1
2
d. Unemployed
1
2
e. An unpaid worker (volunteer)
1
2
f. Retired
1
2
g. In school
1
2
h. A homemaker, housewife, househusband
1
2
i. Disabled
1
2
j. Working multiple jobs
1
2
k. Working temporary job(s)
1
2
T
he
next few questions ask about your current financial situation.
What is your current personal monthly income? Please estimate your monthly income from all sources before taxes are taken out. As with all information you provide on this survey, your answer to this question will be kept confidential.
1 Less than $1,000
2 $1,000 to $1,499
3 $1,500 to $1,999
4 $2,000 to $2,999
5 $3,000 to $3,999
6 $4,000 to $4,999
7 $5,000 to $5,999
8 $6,000 or more
Are you currently receiving any service-related disability compensation?
1 Yes
2 No
Do you have trouble paying your bills?
1 Yes
2 No
Are you currently experiencing difficulty paying your mortgage or is a bank or mortgage broker in the process of foreclosing on your home?
1 Yes
2 No
Do you have any significant outstanding or past due debts, alimony, or child support?
1 Yes
2 No
T
he
next set of questions asks about your health and physical activity.
Do you currently have injuries or health problems as a result of your military experience?
1 Yes
2 No
Do you currently have injuries or health problems not related to your service in the military?
1 Yes
2 No
Are you currently working reduced hours because of illness or injury?
1 Yes
2 No
How much bodily pain have you had during the past 4 weeks?
1 Very severe
2 Severe
3 Moderate
4 Mild
5 Very mild
6 None
Please mark the items that best describe your current health concerns or conditions. (Mark all that apply.)
1 I do not have any of the health concerns or conditions listed below.
-
2 Chronic cough
3 Runny nose
4 Fever
5 Weakness
6 Headaches
7 Swollen, stiff or painful joints
8 Back pain
9 Muscle aches
10 Numbness or tingling in hands or feet
11 Skin diseases or rashes
12 Ringing in the ears
13 Redness of eyes with tearing
14 Dimming of vision (like the lights were going out)
15 Chest pain or pressure
16 Racing heart or heart palpitations
17 Dizziness, fainting, light headedness
20 Difficulty breathing or shortness of breath
21 Diarrhea, vomiting, or frequent indigestion
22 Problems sleeping or still feeling tired after sleeping
21 Difficulty remembering
22 Increased irritability
23 Taking more risks such as driving faster
24 Hearing loss
25 Blurred vision
26 Chronic fatigue
27 Making more mental mistakes than in the past
28 Sexual dysfunction or other sexual problems
29 Other (specify): _____________________________
Please mark the answer that best describes whether each of the following statements is true or false for you.
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Definitely True
Mostly True
Not Sure
Mostly False
Definitely False
a. I am somewhat ill
1
2
3
4
5
b. I am as healthy as anybody I know
1
2
3
4
5
c. My health is excellent
1
2
3
4
5
d. I have been feeling bad lately
1
2
3
4
5
For each of the following questions, please mark one answer for each question below that comes closest to the way you have been feeling during the past month.
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
All the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
a. How much of the time, during the past month, has your health limited your social activities (like visiting with friends or close relatives)?
1
2
3
4
5
6
b. How much of the time, during the past month, have you been a very nervous person?
1
2
3
4
5
6
c. During the past month, how much of the time have you felt calm and peaceful?
1
2
3
4
5
6
d. How much of the time, during the past month, have you felt downhearted and blue?
1
2
3
4
5
6
e. During the past month, how much of the time have you been a happy person?
1
2
3
4
5
6
f. How often, during the past month, have you felt so down in the dumps that nothing could cheer you up?
1
2
3
4
5
6
Since leaving the military, has your doctor told you that you have any of the following?
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes
No
a. Asthma, emphysema or chronic bronchitis (or chronic obstructive pulmonary disease)
1
2
b. Hypertension (high blood pressure)
1
2
c. Diabetes
1
2
d. Respiratory illness
1
2
e. Myocardial infarction, heart attack or heart problems (including angina and chest pain)
1
2
f. High cholesterol
1
2
g. Serious wound or injury
1
2
h. Depression or mental health problem
1
2
i. Cancer
1
2
Since leaving the military, have you been hospitalized due to a serious illness, medical condition, or injury?
1 Yes
2 No
If yes, what illnesses or medical conditions were you hospitalized for? (Mark all that apply.)
1 Asthma, emphysema or chronic bronchitis
2 Hypertension (high blood pressure)
3 Diabetes
4 Respiratory illness
5 Myocardial infarction, heart attack or heart problems
6 Serious wound or injury
7 Depression or other mental health problem
8 Substance use problem
9 Other (specify): _________________________ ______________________________________
Overall, how satisfied or dissatisfied are you with the quality of health care you have received since leaving the military?
1 Very satisfied
2 Somewhat satisfied
3 Somewhat dissatisfied
4 Very dissatisfied
5 I have not received any health care since leaving the military
Since leaving the military, how much of a problem, if any, were delays in health care while you waited for approval from your health plan?
1 A big problem
2 A small problem
3 Not
a problem
Since leaving the military, when you needed care right away for an illness, injury, or condition, how often did you get care as soon as you thought you needed it?
1 Never
2 Sometimes
3 Usually
4 Always
Sometimes people have problems getting medical care or surgery when they need it. Since leaving the military, was there any time when you needed medical care or surgery but did not get it?
1 Yes
2 No
If yes, what was the main reason you didn’t get the care you needed?
1 I did not have the money to pay for care.
2 I had to wait on approval from my health insurance.
3 I could not fit it into my schedule.
4 I could not afford to miss work.
5 I had to wait too long for an appointment.
6 I had to drive too far for the medical care.
7 Other (specify): _________________________ ______________________________________
Which of the following health care coverage do you have?
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes
No
a. Your civilian employer’s health care plan
1
2
b. Your school’s health care plan
1
2
c. Your spouse/family member’s civilian employer’s health care plan
1
2
d. Your active duty military health care coverage (TRICARE/TRICARE Reserve Select)
1
2
e. Your spouse/family member’s active duty/retired military health care coverage
1
2
f. Medicare, Medicaid, or other government sponsored coverage
1
2
g. Veteran’s (VA) coverage
1
2
h. Other private coverage
1
2
i. I do not have medical insurance/health care coverage
1
2
Overall, how satisfied or dissatisfied are you with the health care available to you?
1 Very satisfied
2 Somewhat satisfied
3 Somewhat dissatisfied
4 Very dissatisfied
During the past 30 days, how often did you engage in each of the following kinds of physical activity?
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
About Every Day
5-6 Days a Week
3-4 Days a Week
1-2 Days a Week
Less than 1 day per week
Not at All in the Past 30 days
a. Moderate Physical Activity—A person should feel some exertion but should be able to carry on a conversation comfortably during the activity
1
2
3
4
5
6
b. Vigorous Physical Activity—A person should feel very exerted and find it difficult to carry on a conversation during the activity
1
2
3
4
5
6
T
he
next several questions ask about your use of cigarettes, alcohol,
and drugs, as well as your experiences with the legal system.
Remember all information from this survey will be confidential.
When was the last time you smoked a cigarette?
1 Today
2 During the past 30 days
3 5–8 weeks ago
4 2–3 months ago
5 4–6 months ago
6 7–12 months ago
7 1–3 years ago
8 More than 3 years ago
9 Never smoked cigarettes
Think about the past 30 days. How many cigarettes did you usually smoke on a typical day?
1 More than 35 cigarettes (about 2 packs or more a day)
2 26–35 cigarettes (about 1½ packs a day)
3 16–25 cigarettes (about 1 pack a day)
4 6–15 cigarettes (about ½ pack a day)
5 2–5 cigarettes
6 1 cigarette
7 Less than 1 cigarette a day, on the average
8 I did not smoke cigarettes in the past 30 days
During the past 30 days, on how many days did you drink alcohol?
1 About every day
2 5 to 6 days a week
3 3 to 4 days a week
4 1 to 2 days a week
5 2 to 3 days in the past 30 days
6 Once in the past 30 days
7 I didn’t drink any alcohol in the past 30 days
When you drank alcohol in the past 30 days, about how many drinks did you typically have? (By “drink” we mean a bottle or can of beer, a wine cooler or a glass of wine, a shot of liquor, or a mixed drink or cocktail.)?
1 5 or more drinks
2 4 drinks
3 3 drinks
4 2 drinks
5 1 drink
6 Less than 1 drink
7 I didn’t drink alcohol in the past 30 days
During the past 30 days, what was the largest number of drinks you had on any one occasion?
Enter the number of drinks in the boxes. Use both boxes, ONE number to a box. If you DID NOT drink any alcohol in the past 30 days, please enter “00.”
-
NUMBER OF DRINKS
Since leaving the military, have you ever drunk alcohol or used drugs more than you meant to?
1 Yes
2 No
Have you felt you wanted or needed to cut down on your drinking or drug abuse since leaving the military?
1 Yes
2 No
Since leaving the military, have you been arrested?
1 Yes
2 No
Are there currently any warrants for your arrest, restraining orders against you, or disciplinary actions pending against you?
1 Yes
2 No
Are you currently on probation or parole?
1 Yes
2 No
P
lease indicate how much each statement below describes you.
-
(Place an "X" on each line)
Quite a Lot
Some
A Little
Not at All
I often act on the spur of the moment without stopping to think
1
2
3
4
I get a real kick out of doing things that are a little dangerous
1
2
3
4
People might say I act impulsively
1
2
3
4
I like to test myself every now and then by doing something a little chancy
1
2
3
4
Many of my actions seem to be hasty
1
2
3
4
I'm always up for a new experience
1
2
3
4
I like to try new things just for the excitement
1
2
3
4
I go for the thrills in life when I get a chance
1
2
3
4
I like to experience new and different sensations
1
2
3
4
The
next set of questions asks about your mental or emotional health,
stress, and some other things that |
During the past 30 days, how often did poor mental health keep you from doing your usual activities, such as work or recreation?
1 28-30 days (about every day)
2 20-27 days (5-6 days a week, average)
3 11-19 days (3-4 days a week, average)
4 4-10 days (1-2 days a week, average)
5 2-3 days in the past 30 days
6 Once in the past 30 days
7 Never in the past 30 days
During the past 30 days, how much stress did you experience at work?
1 A lot
2 Some
3 A little
4 None at all
Since leaving the military, have your co-workers or supervisors made negative comments about any recent changes in your appearance, quality of work, or relationships?
1 Yes
2 No
Since leaving the military, have you had a physical or mental condition that caused you to loose your job?
1 Yes
2 No
How many times have you changed jobs since leaving the military?
Enter the number of job changes in the boxes. Use both boxes, ONE number to a box. If you have NOT had any jobs since leaving the military, please enter “00.”
-
NUMBER OF JOB CHANGES
Since leaving the military, how often have you been late for work due to emotional or physical problems?
1 More than 10 times
1 9 or 10 times
1 6 to 8 times
2 3 to 5 times
3 1 or 2 times
4 0 times
Since leaving the military, how much stress have you experienced in your family life? “Family life” refers to your relationship(s) with your spouse and children, or with your live-in fiancé, boyfriend or girlfriend, or the person you date seriously.
1 A lot
2 Some
3 A little
4 None at all
How much stress has your spouse been under since you left the military?
1 A lot
2 Some
3 A little
4 None at all
5 I don’t have a spouse
Please indicate how much you agree with the following statements as they apply to you over the last month. If a particular situation has not occurred recently, answer according to how you think you would have felt.
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
True Nearly All the Time
Often True
Sometimes True
Rarely True
Not True at All
a. I am able to adapt when changes occur
1
2
3
4
5
b. I have at least one close and secure relationship which helps me when I am stressed
1
2
3
4
5
c. When there are no clear solutions to my problems, sometimes fate or God can help
1
2
3
4
5
d. I can deal with whatever comes my way
1
2
3
4
5
e. Past successes give me confidence in dealing with new challenges and difficulties
1
2
3
4
5
f. I try to see the humorous side of things when I am faced with problems
1
2
3
4
5
g. Having to cope with stress can make me stronger
1
2
3
4
5
h. I tend to bounce back after illness, injury, or other hardships
1
2
3
4
5
i. Good or bad, I believe that most things happen for a reason
1
2
3
4
5
j. I give my best effort, no matter what the outcome may be
1
2
3
4
5
k. I believe I can achieve my goals, even if there are obstacles
1
2
3
4
5
l. Even when things look hopeless, I don’t give up
1
2
3
4
5
m. During times of stress/crisis, I know where to turn for help
1
2
3
4
5
n. Under pressure, I stay focused and think clearly
1
2
3
4
5
o. I prefer to take the lead in solving problems, rather than letting others make all the decisions
1
2
3
4
5
p. I am not easily discouraged by failure
1
2
3
4
5
q. I think of myself as a strong person when dealing with life’s challenges and difficulties
1
2
3
4
5
r. I can make unpopular or difficult decisions that affect other people, if it is necessary
1
2
3
4
5
s. I am able to handle unpleasant or painful feelings like sadness, fear and anger
1
2
3
4
5
t. In dealing with life’s problems, sometimes you have to act on a hunch, without knowing why
1
2
3
4
5
u. I have a strong sense of purpose in life
1
2
3
4
5
v. I feel in control of my life
1
2
3
4
5
w. I like challenges
1
2
3
4
5
x. I work to attain my goals, no matter what roadblocks I encounter along the way
1
2
3
4
5
y. I take pride in my achievements
1
2
3
4
5
Since leaving the military, how much stress did you experience from each of the following?
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
A Lot
Some
A Little
None at All
a. Problems in my relationships with the people I work with
1
2
3
4
b. Problems in my relationship with my immediate supervisor(s)
1
2
3
4
c. Increases in my work load
1
2
3
4
d. Decreases in my work load
1
2
3
4
e. Conflicts between my work and family responsibilities
1
2
3
4
f. Having a baby
1
2
3
4
g. Finding childcare/daycare
1
2
3
4
h. Death in the family
1
2
3
4
i. Divorce or breakup
1
2
3
4
j. Infidelity or unfaithfulness by you or your spouse, fiancé, boyfriend, or girlfriend
1
2
3
4
k. Problems with money
1
2
3
4
l. Problems with housing
1
2
3
4
m. Health problems that I had
1
2
3
4
n. Health problems that my family members had
1
2
3
4
o. Behavioral or emotional problems in some of my children
1
2
3
4
p. Unexpected events/problems (i.e., hurricane, flood, home robbery)
1
2
3
4
q. Problems obtaining appropriate/necessary health care
1
2
3
4
r. Getting along with others
1
2
3
4
s. Finding employment
1
2
3
4
t. Insufficient civilian job skills
1
2
3
4
During the past 30 days, how often have you been bothered by the following?
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
More than Half of the Days
Several Days
Not at All
a. Feeling nervous, anxious, on edge, or worrying a lot about different things
1
2
3
b. Getting tired very easily
1
2
3
c. Muscle tension, aches, or soreness
1
2
3
d. Trouble falling asleep or staying asleep
1
2
3
e. Trouble concentrating on things, such as reading a book or watching TV
1
2
3
f. Becoming easily annoyed or irritable
1
2
3
g. Feeling restless so that it is hard to sit still
1
2
3
Over the past month, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?
1 Yes
2 No
If yes, about how often have you been bothered by these thoughts?
1 Very few days
2 More than half of the time
3 Nearly every day
If you are having any suicidal thoughts or other psychological distress, please seek help immediately. We encourage you to contact a mental health professional. You could contact the counseling hotline at 1-800-784-2433 or 1‑800-SUICIDE. This is an anonymous, civilian hotline. |
Below is a list of ways you might have felt or behaved. Please indicate how often you felt this way during the past week:
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Most or All of the Time
(5–7 Days)Occasionally or a Moderate Amount of Time
(3–4 Days)Some or a Little of the Time (1–2 Days)
Rarely or None of the Time (Less Than 1 Day)
a. I was bothered by things that usually don’t bother me
1
2
3
4
b. I did not feel like eating; my appetite was poor
1
2
3
4
c. I felt that I could not shake off the blues even with help from my family and friends
1
2
3
4
d. I felt that I was just as good as other people
1
2
3
4
e. I had trouble keeping my mind on what I was doing
1
2
3
4
f. I felt depressed
1
2
3
4
g. I felt like everything I did was an effort
1
2
3
4
h. I felt hopeful about the future
1
2
3
4
i. I thought my life had been a failure
1
2
3
4
j. I felt fearful
1
2
3
4
k. My sleep was restless
1
2
3
4
l. I was happy
1
2
3
4
m. I talked less than usual
1
2
3
4
n. I felt lonely
1
2
3
4
o. People were unfriendly
1
2
3
4
p. I enjoyed life
1
2
3
4
q. I had crying spells
1
2
3
4
r. I felt sad
1
2
3
4
s. I felt that people disliked me
1
2
3
4
t. I could not ‘get going’
1
2
3
4
Below is a list of problems and complaints that people sometimes have in response to stressful experiences. Please indicate how much you have been bothered by each problem in the past month.
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Extremely
Quite a Bit
Moderately
A Little Bit
Not at All
a. Repeated, disturbing memories, thoughts or images of a stressful experience
1
2
3
4
5
b. Repeated, disturbing dreams of a stressful experiences
1
2
3
4
5
c. Suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)
1
2
3
4
5
d. Feeling very upset when something reminded you of a stressful experience
1
2
3
4
5
e. Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience
1
2
3
4
5
f. Avoiding thinking about or talking about a stressful experience or avoiding having feelings related to it
1
2
3
4
5
g. Avoiding activities or situations because they reminded you of a stressful experience
1
2
3
4
5
h. Trouble remembering important parts of a stressful experience
1
2
3
4
5
i. Loss of interest in activities you used to enjoy
1
2
3
4
5
j. Feeling distant or cut off from other people
1
2
3
4
5
k. Feeling emotionally numb or being unable to have loving feelings for those close to you
1
2
3
4
5
l. Feeling as if your future somehow will be cut short
1
2
3
4
5
m. Trouble falling or staying asleep
1
2
3
4
5
n. Feeling irritable or having angry outbursts
1
2
3
4
5
o. Having difficulty concentrating
1
2
3
4
5
p. Being “superalert” or watchful or on guard
1
2
3
4
5
q. Feeling jumpy or easily startled
1
2
3
4
5
In general, how long have you experienced the problems listed in Question 52?
1 I have never had any of these problems or complaints.
2 Less than 1 month
3 1 month
4 2 to 3 months
5 4 to 6 months
6 7 months or longer
Since leaving the military, have you had problems sleeping because of nightmares?
1 Yes
2 No
Since leaving the military, have you had problems with anger, frustration, resentment, hostility or losing your temper?
1 Yes
2 No
How much trouble have you had adjusting to civilian life?
1 A lot
2 Some
1 A little
2 None at all
Since leaving the military, did you . . .
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes,
But Only 1 TimeYes,
2 or 3 TimesYes,
More Than 3 TimesNo
a. Drive a car or other vehicle when you had too much to drink?
1
2
3
4
b. Drive or ride in a boat, canoe, or other watercraft when you had too much to drink?
1
2
3
4
c. Ride or drive a motorcycle without a helmet?
1
2
3
4
F
or
the next questions, “mental health professional” refers
to a psychologist, psychiatrist, clinical social worker, or other
mental health counselor.
Since leaving the military, did you receive counseling or therapy for mental health or substance abuse from the following?
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes
No
a. Civilian mental health professional (e.g., psychologist, psychiatrist, clinical social worker or other mental health counselor)
1
2
b. Civilian general medical doctor
1
2
c. VA mental health professional (e.g., psychologist, psychiatrist, clinical social worker or other mental health counselor)
1
2
d. VA general medical doctor
1
2
e. Pastor, rabbi, or other pastoral counselor
1
2
f. Self-help group (AA, NA)
1
2
F
or
what concerns did you seek counseling or therapy since leaving
the military? (Mark all that apply.)
1 Depression
2 Anxiety
3 Children’s problems
4 Marriage problems
5 Substance use problems
6 Anger management
7 Stress management
8 Combat/operational stress
9 Other (specify): ______________________________
10 I did not seek help from a mental health professional since leaving the military
Since leaving the military, did you feel you needed counseling or therapy from a mental health professional?
1 Yes
2 No
Are you currently receiving counseling or therapy for mental health or substance abuse problems?
1 Yes
2 No
Have you been prescribed medication for depression, anxiety, or sleeping problems by a doctor or other health professional? (Mark all that apply.)
1 Yes, in the past 30 days
2 Yes, more than 30 days ago but since leaving the military
3 No
Since leaving the military, have your children experienced or behaved in any of the following ways?
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.) |
Yes |
No |
I Do Not Have Any Children |
a. Declining academic performance or grades |
1 |
2 |
3 |
b. Disruptive or problem behavior |
1 |
2 |
3 |
c. Social withdrawal from peers |
1 |
2 |
3 |
d. Bullying |
1 |
2 |
3 |
e. Alcohol or drug use |
1 |
2 |
3 |
T
he
next set of questions asks about your religious or spiritual
practices.
Since leaving the military, how many times have you attended religious services? (Please do not include special occasions, such as weddings, funerals, or other special events in your answer.)
1 More than 26 times
2 12–25 times
3 6–11 times
4 3–5 times
5 1–2 times
6 0 times
My religious/spiritual beliefs are a very important part of my life.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
My religious/spiritual beliefs influence how I make decisions in my life.
1 Strongly agree
2 Agree
3 Disagree
4 Strongly disagree
The next few questions ask about events that you may have experienced since leaving the military.
Since leaving the military, I have experienced…
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes
No
a. a natural disaster (for example, a flood or hurricane), a fire, or an accident in which I was hurt or my property was damaged
1
2
b. exposure to a toxic substance (such as dangerous chemicals or radiation).
1
2
c. combat or exposure to a war-zone (as a civilian)
1
d. a serious surgery or operation
1
2
e. a mental illness (for example, clinical depression or anxiety disorder) of someone close to me, or a life-threatening physical illness (for example, cancer or heart disease) of someone close to me
1
2
f. the death of someone close to me
1
2
g. stressful legal problems (for example, being sued or suing someone else)
1
2
Since leaving the military, I have…
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Yes
No
a. witnessed someone being assaulted or violently killed
1
2
b. been robbed or had my home broken into
1
2
c. had a family member with a drug or alcohol problem
1
2
d. been unemployed and seeking employment for at least 3 months
1
2
e. been emotionally mistreated (for example, shamed, embarrassed, ignored, or repeatedly told I was no good)
1
2
f. experienced unwanted sexual activity as a result of force, threat of harm, or manipulation
1
2
g. been physically injured by another person (for example, hit, kicked, or beaten up)
1
2
h. been threatened with a weapon
1
2
i. lost my job
1
2
j. had problems getting access to adequate health care
1
2
k. lost my temper and hurt another person
1
2
l. been fired from a job…………………………………………………………………………………………….
1
2
m. gone through a divorce or been left by a partner or significant other
1
2
n. had a serious illness (for example, cancer or heart disease)
1
2
The next question asks about your current relationships and social support. Social support refers to the extent that people listen and care about what happened to you.
The statements below are about your current relationships with others, including family and friends.
-
(Mark an answer for each question below. Indicate your answer by placing an “X” in the box for your response.)
Strongly Agree
Somewhat Agree
Neither Agree nor Disagree
Somewhat Disagree
Strongly Disagree
a. I am carefully listened to and understood by family members or friends
1
2
3
4
5
b. Among my friends or relatives, there is someone who makes me feel better when I am feeling down
1
2
3
4
5
c. I have problems that I can’t discuss with family or
friends1
2
3
4
5
d. Among my friends or relatives, there is someone I go to when I need good advice
1
2
3
4
5
e. People at home just don’t understand what I have been through while in the Armed Forces
1
2
3
4
5
f. There are people to whom I can talk about my military experiences
1
2
3
4
5
g. The people I work with respect the fact that I am a veteran
1
2
3
4
5
h. My supervisor understands when I need time off to take care of personal matters
1
2
3
4
5
i. My friends or relatives would lend me money if I
needed it1
2
3
4
5
j. My friends or relatives would help me move my belongings if I needed to
1
2
3
4
5
k. When I am unable to attend to daily chores, there is someone who will help me with these tasks
1
2
3
4
5
l. When I am ill, friends or family members will help out until I am well
1
2
3
4
5
Do you know at least one military veteran that you talk to about your war experiences or other stressful deployment events?
1 Yes
2 No
If yes, has talking to another veteran helped you handle stress better?
1 Yes
2 No
Do you have the opportunity to interact with a group of combat veterans?
1 Yes
2 No
If yes, what type of group(s)? (Mark all that apply.)
1 Social Group
2 Support Group
3 Reserve Unit
4 Sports Team
5 Other (specify): __________________________
Please feel free to share any comments you may have about this survey: _________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
THANK YOU VERY MUCH FOR YOUR TIME, EFFORT, AND COOPERATION IN COMPLETING THIS QUESTIONNAIRE.
-
| File Type | application/msword |
| File Title | 2001 DEPARTMENT OF DEFENSE |
| Last Modified By | creyes |
| File Modified | 2007-12-18 |
| File Created | 2007-12-18 |
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