Form VA Form Number 10- VA Form Number 10- Operation Enduring Freedom/Operation Iraqi Freedom Veter

OMB Number 2900-XXXX
Estimated Burden 20 minutes
VA Form 10-21091

Department of Veterans Affairs

OIF/OEF OIF/OEF OIF/OEF
Enduring
Freedom/ OIF
OEF Operation
OIF/OEF
OIF/OEF
Operation Iraqi Freedom
OIF/OEF
OIF/OEF
OIF/OEF
Veterans Health and Needs Assessment
OEF OIF/OEF
OIF/OEF
OIF
SURVEY
OIF/OEF OIF/OEF OIF/OEF
PRIVACY ACT STATEMENT
The information requested on this survey is solicited under authority of 38 U.S.C. Part I, Chapter
5, Section 527. It is being collected to assist VA in learning more about the health of OEF/OIF
veterans and will help VA to provide better medical care. The information you supply will be
confidential and protected by the provisions of the Privacy Act of 1974 (5 U.S.C. 552A). Disclosure
is voluntary; failure to furnish the requested information will have no adverse effect on any VA
benefit to which you may be entitled.
PAPERWORK REDUCTION ACT INFORMATION: This information is collected in
accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act
of 1995. Accordingly, VA may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB control number. VA anticipates that the
time expended by all individuals who complete this survey will average 20 minutes. This includes
the time it will take to read instructions, gather the necessary facts, and fill out the survey. The
information requested on this survey will be used to help VA assess the health status of veterans
and plan health care services. A response to this survey is voluntary.

U.S. Department of Veterans Affairs
Operation Enduring Freedom/Operation Iraqi Freedom
Veterans Health and Needs Assessment
1. Did you serve in Afghanistan or
neighboring countries in support of Operation
Enduring Freedom (OEF)?
Yes

No

2. Did you serve in Iraq or elsewhere in the
Persian Gulf in support of Operation Iraqi
Freedom (OIF)?
Yes

3. How many times were you deployed during
OEF/OIF?
3 times
4 times or more

4. In TOTAL, how many months were you
deployed in OEF/OIF?
1 to 4 months
5 to 8 months
9 to 12 months
13 to 16 months
17 to 20 months
21 to 24 months

25 to 28 months
29 to 32 months
33 to 36 months
37 to 40 months
41 months or more

5. In what year did you last RETURN home
from deployment during OEF/OIF?
2001
2002
2003

2004
2005
2006

2007
2008 or
later

6. While serving in OEF/OIF, were you in
the ...?
Reserves
National Guard

Army
Air Force
Coast Guard

Regular Active
Duty

Navy
Marines

8. During OEF/OIF, what was your highest
rank?
E1 to E4
E5 to E7
E8 or higher

No

1 time
2 times

7. During OEF/OIF, were you in the ...?

O1 to O3
O4 or higher

9. During OEF/OIF, what was your primary
military occupation (MOS, SSI, NEC, NOBC,
or AFSC) code?

10. Please briefly describe what your unit was
assigned to do during OEF/OIF. For example,
transportation, moving equipment, etc.

11. What is your current military status?
Reserves
National Guard

Regular Active Duty
Separated/Retired

12. How were you separated/retired?
Still on Active Duty, in Reserves or National
Guard
At the end of full period of service
Military retirement after normal length of
service
Military retirement due to disability
Medical release due to injury
Medical release due to pregnancy
Other than honorable discharge
Other, specify

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13. During your deployment, did you suffer
any SERVICE-CONNECTED injuries?
Yes

17. Which of the following problems related to
a head injury or concussion do you currently
have? MARK ALL THAT APPLY

No SKIP TO Q15

14. Did you have any injury(ies) during your
deployment from any of the following? MARK
ALL THAT APPLY
Fragment wound
Bullet wound
Vehicle accident (tank, boat, plane, etc.)
Fall
Blast/explosion (IED, RPG, land mine,
grenade, etc.)
Physical training or sports
Other, specify _______________________
15. What is your VA service-connected
disability rating? MARK ONLY ONE
None, never applied
None, claim is still pending
None, claim was denied
0%
10%
60%
20%
70%
30%
80%
40%
90%
50%
100%
16. Did ANY injury you received during
deployment result in any of the following?
MARK ALL THAT APPLY
Required a hospital stay or medical
evacuation
Being dazed, confused, or "seeing stars"
Losing consciousness for less than 1
minute
Losing consciousness for 1 to 20 minutes
Losing consciousness for longer than 20
minutes
Not remembering the injury
Having any symptoms of concussion
afterward (e.g., headache, dizziness,
irritability, etc.)
Head or brain injury
None of the above

Headaches
Dizziness
Memory problems
Balance problems
Ringing in the ears
Irritability
Sleep problems
Sensitivity to bright light
Other, specify
None of these
18. In general, would you say your health now
is ...
Excellent
Very good
Good
Fair
Poor
19. Does your health limit you in moderate
activities, such as moving a table, pushing a
vacuum cleaner, bowling or playing golf?
Yes, limited a lot
Yes, limited a little
No, not limited at all
20. Have you ever smoked cigarettes?
Yes, still smoking every day
Yes, still smoking some days
Yes, but no longer smoke at all
No, never smoked
21. Have you ever used chewing tobacco,
snuff, or other smokeless tobacco?
Yes, still use every day
Yes, still use some days
Yes, but no longer use at all
No, never used smokeless tobacco
22. In thinking about your weight, do you
consider yourself to be ...
Overweight
About the right weight
Underweight

Over the past two weeks, how often have you
been bothered by the following problems?

30. Have you felt you wanted or needed to cut
down on your drug use in the past year?

23. Little interest or pleasure in doing things

Yes
Not applicable

No

24. Feeling down, depressed, or hopeless
Not at all . . . . . . . . . . . . . . . . . . . . . . . . .
Several days . . . . . . . . . . . . . . . . . . . . . .
More than half the days. . . . . . . . . . . . . .
Nearly every day . . . . . . . . . . . . . . . . . . .

31. In the past year, have you felt you wanted
or needed to cut down on aggressive driving
or "road rage"?
Yes

25. How often did you have a drink containing
alcohol in the past year?

32. How often do you use a seat belt when you
drive or ride in a car?

Never
SKIP TO Q29
Monthly or less
Two or three times a month
Two or three times a week
Four or more times a week
26. How many drinks did you have on a typical
day when you were drinking in the past year?
1 or 2 drinks
3 or 4 drinks
5 or 6 drinks
7 to 9 drinks
10 or more drinks

Always
Nearly always
Sometimes
Seldom
Never
33. Has a doctor or other health care provider
ever said that you have any of the following
CONDITIONS?
Yes No

27. How often did you have six or more drinks
on one occasion in the past year?
Never
1 or 2 times
3 or 4 times
5 or 6 times
7 to 9 times
10 or more times
28. In the past 12 months, has a health care
provider advised you about your drinking (to
drink less or not to drink)?
No
Yes, a VA provider
Yes, a non-VA provider
29. In the past year, have you ever used drugs
more than you meant to?
Yes

No

No

a.
b.
c.
d.

Fibromyalgia . . . . . . . . . . . . . . . . .
Chronic Fatigue Syndrome . . . . . .
Irritable Bowel Syndrome . . . . . . .
Post Traumatic Stress Disorder
(PTSD) . . . . . . . . . . . . . . . . . . . . .
e. Head injury (Traumatic Brain
Injury-TBI). . . . . . . . . . . . . . . . . . .
f. Depression . . . . . . . . . . . . . . . . . .
g. Asthma and other breathing
problems. . . . . . . . . . . . . . . . . . . .
h. Allergies . . . . . . . . . . . . . . . . . . . .
i. Sinusitis. . . . . . . . . . . . . . . . . . . . .
j. Hearing loss . . . . . . . . . . . . . . . . .
k. Arthritis . . . . . . . . . . . . . . . . . . . . .
l. Diabetes or high blood sugar. . . . .
m. Heart problems (cardiac). . . . . . . .
n. Cancer . . . . . . . . . . . . . . . . . . . . .
o. High blood pressure (hypertension).
p. Ulcers . . . . . . . . . . . . . . . . . . . . . .
q. Traumatic injury (involving loss of a
limb). . . . . . . . . . . . . . . . . . . . . . . .
r. Liver problems. . . . . . . . . . . . . . . .
s. Kidney problems . . . . . . . . . . . . . .
t. Epilepsy or Seizures . . . . . . . . . . .
u. Skin rashes (dermatitis). . . . . . . . .

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34. Have you experienced any of the following
SYMPTOMS during the last month?
Severity of symptoms is defined as follows:
MILD - Just aware, but not slowed down by
the symptoms, or sufficient to take
non-prescription drugs to relieve symptoms
(aspirin, Tums, etc.)
SEVERE - Sufficient to seek medical advice,
take prescription drugs, miss work, or limit
routine activities.
Severe
Mild
None
a.
b.
c.
d.

Stomach pain . . . . . . . . . . . . . . . . .
Back pain . . . . . . . . . . . . . . . . . . . .
Pain in your arms, legs, or joints. . .
Generalized muscle aching or
cramps . . . . . . . . . . . . . . . . . . . . . .
e. Problems with your menstrual cycle
or fertility problems . . . . . . . . . . . . .
f. Pain or problems during sexual
intercourse . . . . . . . . . . . . . . . . . . .
g. Headaches . . . . . . . . . . . . . . . . . . .
h. Chest pain. . . . . . . . . . . . . . . . . . . .
i. Dizziness. . . . . . . . . . . . . . . . . . . . .
j. Fainting spells. . . . . . . . . . . . . . . . .
k. Feeling your heart pound or race . .
l. Shortness of breath. . . . . . . . . . . . .
m. Constipation . . . . . . . . . . . . . . . . . .
n. Loose bowels or diarrhea. . . . . . . .
o. Nausea, gas, or indigestion. . . . . . .
p. A sore throat, hoarse voice or
throat problems (not related to a
cold) . . . . . . . . . . . . . . . . . . . . . . . .
q. Fatigue lasting more than 24 hours
after exertion. . . . . . . . . . . . . . . . . .
r. Skin disorders, itching, or extreme
dryness. . . . . . . . . . . . . . . . . . . . . .
s. Hearing loss or ringing in the ears. .
t. Teeth grinding. . . . . . . . . . . . . . . . .
u. Sexual disinterest or impotence . . .
v. Vision problems. . . . . . . . . . . . . . .
w. Dental problems or pain . . . . . . . . .
x. Coughing, wheezing, sinus, or
breathing problems. . . . . . . . . . . . .

35. Please rate the severity of your muscle
and/or joint pain AT THIS MOMENT on the
following scale?
No
Pain

0

1

2

3

4

5

6

7

8

9

10

Extreme
Pain

36. Very often when serving in a combat area
people experience difficult situations. Please
mark which of the following you have
experienced while deployed. MARK ALL
THAT APPLY
Being attacked or ambushed
Receiving incoming artillery, rocket, or
morter fire, or an IED
Being shot at or receiving small arms fire
Shooting or directing fire at the enemy
Being responsible for the death of an
enemy combatant
Being responsible for the death of a
non-combatant
Seeing dead bodies or human remains
Handling or uncovering human remains
Seeing dead or seriously injured
Americans
Knowing someone seriously injured or
killed
Participating in demeaning operations
Seeing ill or injured women and children
whom you could not help
Had a close call, was shot at or hit, but
protective gear saved you
Had a buddy shot or hit who was near you
Clearing or searching buildings
Engaging in hand-to-hand combat
Saved the life of a soldier or civilian
Experienced sexual assault or rape
Experienced sexual harassment or abuse
None of these

37. Below is a list of problems and complaints that veterans sometimes have in response to
stressful experiences. In the last month, how much have you ...
Extremely
Quite a lot
Moderately
A little bit
None
a. Had repeated, disturbing memories, thoughts, or images of a stressful military
experience from the past. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Had repeated, disturbing dreams of a stressful military experience from the past. . . . .
c. Suddenly acted or felt as if a stressful military experience were happening again (as if
you were reliving it) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Felt very upset when something reminded you of a stressful military experience. . . . . .
e. Had physical reactions (e.g., heart pounding, trouble breathing, or sweating) when
something reminded you of a stressful military experience . . . . . . . . . . . . . . . . . . . . . .
f. Avoided thinking about or talking about a stressful military experience from the past or
avoided having feelings related to it. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
g. Avoided activities or situations because they remind you of a stressful military
experience from the past. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
h. Had trouble remembering important parts of a stressful military experience. . . . . . . . .
i. Lost interest in things that you used to enjoy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
j. Felt distant or cut off from other people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
k. Felt emotionally numb or being unable to have loving feelings for those close to you . .
l. Felt as if your future will somehow be cut short . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
m. Had trouble falling or staying asleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n. Felt irritable or had angry outbursts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
o. Had difficulty concentrating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
p. Felt “super alert” or watchful or on guard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q. Felt jumpy or easily startled. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38. During the past year have you been unable
to get health care because you don't have
insurance coverage or you can't pay?
Yes, unable to get care

No

39. How far away is the nearest VA hospital or
clinic from your home?
Less than 30 min.
30-59 minutes
60-89 minutes

90-120 minutes
More than 120 min.
(More than 2 hours)

40. How would you normally get to the VA
hospital or clinic?
Bus
Taxi

Personal car
DAV van

Other, specify
Never used VA health care
41. How convenient is the location of the
nearest VA hospital or clinic for you to use?
Very convenient
Somewhat convenient
Somewhat inconvenient
Very inconvenient

42. What would make using a VA facility more
convenient? MARK UP TO FIVE
Location closer to home
Safer location
Better handicapped accessibility
Better public or VA transportation
Better buildings/facilities
Improved parking
Valet parking
Evening Clinics
Weekend Clinics
Walk-in Clinics
Family more involved in my care
On-site child care
Child-friendly environment
Less time in waiting room
Less time between appointments
Easier to reach my doctor
Waiting rooms for women only
All VA appointments on same day
More time with my doctor
Staff shows more concern/respect
Just not interested
Other, specify

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43. Since your last deployment, which, if any,
have you used? MARK ALL THAT APPLY
Used VA for health care services
Used non-VA for health care services
Have not used any health care services
44. What are the main reasons that you would
NOT choose a VA hospital or clinic for your
health care? MARK ALL THAT APPLY
Want to use my own local doctor
Prefer to be treated elsewhere
Want to use Tri-Care
Entitled to military/DoD medical care
Have other health insurance
VA doesn't offer the care I need
Quality of care is poor at VA
Staff lacks knowledge/expertise
Inconsiderate staff at VA
Don't think I'm eligible
VA facilities are unpleasant
Worried about confidentiality of my records
Lack of privacy
Poor quality of VA health care providers
VA refused to give me the care I needed
Treated elsewhere at VA expense
Live too far from a VA medical center
Dangerous location of VA facility
Too much red tape
Inadequate parking
Other, specify

45. Since your deployment, have you tried to
get mental health counseling? MARK ALL
THAT APPLY
Yes, from a VA hospital or clinic
Yes, from a Vet Center
Yes, from my chaplain or religious leader
Yes, from a non-VA provider
No
46. How many times have you seen a doctor
or health care provider for PHYSICAL
problems in the last 12 months?
Never
1 or 2 times
3 to 5 times
6 or more times

47. How many times have you seen a doctor or
received counseling or therapy for
READJUSTMENT or EMOTIONAL problems in
the last 12 months?
Never
1 or 2 times
3 to 5 times
6 or more times
48. Veterans with readjustment problems
following deployment may not seek mental
health services for a number of reasons.
Please rate how much you agree or disagree
with each statement as it applies to you.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
a. I don't know where to go for
help. . . . . . . . . . . . . . . . . . . . .
b. I don't have adequate
transportation . . . . . . . . . . . . .
c. I just don't have the time . . . . .
d. It's hard getting time off work
for treatment . . . . . . . . . . . . . .
e. It might harm my career. . . . .
f. My unit or co-workers might
have less confidence in me. . .
g. My unit leadership or employer
might treat me differently. . . . .
h. I would be seen as weak by
others . . . . . . . . . . . . . . . . . . .
i. Visits would not remain
confidential . . . . . . . . . . . . . . .
j. I don't trust mental health
professionals. . . . . . . . . . . . . .
k. I am concerned about the cost
of treatment. . . . . . . . . . . . . . .
l. I don't want to talk about my
war experiences . . . . . . . . . . .
m. I don’t want to be prescribed
medications. . . . . . . . . . . . . . .
n. I don't think treatment will help
me . . . . . . . . . . . . . . . . . . . . .
o. It's up to me to work out my
own problems . . . . . . . . . . . . .
p. Treatment would make me feel
down on myself. . . . . . . . .
q. It is difficult getting childcare. .

49. How likely would you be to use the
following services if they were offered by VA?
Very likely
Somewhat likely
Not likely
a. Help getting your marriage back on
track . . . . . . . . . . . . . . . . . . . . . . . .
b. Help getting back in touch with your
kids. . . . . . . . . . . . . . . . . . . . . . . . .
c. Information and support for your
family about normal readjustment
problems. . . . . . . . . . . . . . . . . . . . .
d. Help getting a job . . . . . . . . . . . . . .
e. Help with school or career
decisions. . . . . . . . . . . . . . . . . . . . .
f. Help handling stress . . . . . . . . . . . .
g. Help dealing with anger and
irritability . . . . . . . . . . . . . . . . . . . . .
h. Help learning about benefits . . . . . .
i. Help with pain management. . . . . .
j. Help with sleep problems . . . . . . . .
k. Help with smoking cessation. . . . . .
l. Help with weight control . . . . . . . . .
m. Information about chemical or
infectious exposures while deployed
overseas . . . . . . . . . . . . . . . . . . . . .
n. Hearing tests . . . . . . . . . . . . . . . . .
o. Help with managing breathing
problems. . . . . . . . . . . . . . . . . . . . .
p. Peer counseling with other veterans
q. Financial counseling . . . . . . . . . . . .
r. Assistance with physical
rehabilitation . . . . . . . . . . . . . . . . . .
s. Eye exams . . . . . . . . . . . . . . . . . . .
t. Dental exams . . . . . . . . . . . . . . . . .
u. Readjustment help if offered within
primary care . . . . . . . . . . . . . . . . . .
v. Help with substance use/
dependence . . . . . . . . . . . . . . . . . .
w. Multi-lingual services. . . . . . . . . . . .
x. Info about exposure to chemicals
and toxins . . . . . . . . . . . . . . . . . . . .
y. Other, specify

50. Since demobilization, have you ever
received any information from VA explaining
their programs and benefits?
Yes

No

51a. People learn about VA programs from
different sources. Did you receive any
information about VA programs from the
following sources?
No
Yes
a.
b.
c.
d.
e.
f.
g.

Newspapers or magazines . . . . . . .
Television . . . . . . . . . . . . . . . . . . . .
Radio . . . . . . . . . . . . . . . . . . . . . . .
VA information or publications. . . . .
Other government publications. . . .
Other veterans . . . . . . . . . . . . . . . .
Counseling and advice you got at
discharge from the service . . . .
h. Post Deployment Health
Reassessment (PDHRA). . . . . . .
i. Veterans' organizations (American
Legion, VFW, DAV, etc.). . . . . . . . .
j. Website. . . . . . . . . . . . . . . . . . . . . .
k. Friends, family, and co-workers . . .
l. Chaplain or religious leader . . . . . .
m. Command/superiors . . . . . . . . . . . .
n. Family Readiness Groups. . . . . . . .
o. Combat Stress Control or
Behavioral Health contacts . . . . .
p. Toll-free hotline . . . . . . . . . . . . . . .
q. Military OneSource . . . . . . . . . . . . .
r. Other, specify

51b. In the last column above, please
indicate how you would prefer to receive
information from in the future.
MARK ONLY THREE

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DEMOGRAPHICS

56. Please indicate if you have DEPENDENT
children in any of the following age groups.
MARK ALL THAT APPLY

52. Are you ...
Male

Female

53. How old are you?
______ years old

19 to 24 years old
None

57. What was your approximate household

54. Are you currently ...
Single, never married
Married
Committed/living as
married

Under 5 years old
5 to 8 years old
9 to 11 years old
12 to 18 years old

Separated
Divorced
Widowed

55. How would you describe your employment
status during the past week? MARK ALL
THAT APPLY
Active Duty Military
Employed full-time as a civilian
Employed part-time as a civilian
Unemployed, but looking for work
Unemployed, but NOT looking for work
Retired
Disabled
A homemaker
A student

Less than $20,000
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999

$50,000-$59,999
$60,000-$74,999
$75,000-$99,999
$100,000 or more

58. Do you consider yourself Hispanic or
Latino?
Yes

No

59. Do you consider yourself ...
Asian
African-American
Native American or
Alaska Native

Pacific Islander
White
Other, specify

60. If it was available, would you have
preferred to complete this survey on the Web?
Yes

No
No

That concludes the survey.
Your input is very valuable to us and we would like to thank you for your participation
and cooperation. We very much appreciate your time and honesty in answering these
questions. We want to remind you that this is an anonymous survey so there is no way for
anyone to link your responses to your identity.
If you have any questions or concerns about this study or if any part of this survey has
been upsetting for you, and you would like to talk to someone, you can contact Dr. Patrick
Calhoun or Dr. Kristy Straits-Tröster at the Durham VAMC toll free at (888) 878-6890
extension 6154, Monday through Friday from 9 AM to 5 PM Eastern Standard Time. If you
have questions about the research, you may contact the administrative officer of the
research service at the Durham VAMC at (919) 286-0411 ext. 7632.
If you or anyone you know are having thoughts about hurting or killing yourself, please
call the free, confidential Suicide Prevention Hotline at 1-800-273-TALK (8255).
If you'd like more information about the VA and benefits please go to www.va.gov on the
internet.
Please return the completed survey in the enclosed postage-paid envelope to:
Abt SRBI Inc.
8403 Colesville Road, Suite 820 Silver Spring, MD 20910