Form VA Form 10-0478 VA Form 10-0478 Health Care Use Survey for Enduring Freedom and Operatio

Health-Care Use Survey for Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans

VA Form 10-0478_Health-Care Use Survey (v4)[1]

Health-Care Use Survey for Enduring Freedom and Operation Iraqi Freedom Veterans

OMB: 2900-0765

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Department of Veterans Affairs

HEALTH-CARE USE SURVEY
FOR ENDURING FREEDOM AND
OPERATION IRAQI FREEDOM
(OEF/OIF) VETERANS

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 45 minutes. This includes the time it will take to
read instructions, gather the necessary capabilities.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under the
authority of Title 38, U.S.C., Part I, Chapter 5, Section 527 that authorizes the collection
of data that will allow measurement and evaluation of the Department of Veterans Affairs
Programs. Your obligation to respond is voluntary. Participants will be assured that all data will be
kept confidential and no identifying information will be used in any dissemination activities. Study
participants will review an information sheet that contains all the elements of an informed consent
form. Participants are not required to complete any portion of the consent page. Completion of
the survey implies consent. All data collection procedures will be approved by the Institutional
Review Board (IRB) at the VA Boston Healthcare System.

VA Form 10-0478
October 2009

OMB 2900-XXXX

OMB 2900-XXXX
Estimated Burden: 45 min.

Department of Veterans Affairs

HEALTH-CARE USE SURVEY
ENDURING FREEDOM AND OPERATION IRAQI FREEDOM (OEF/OIF) VETERANS

Either based on your own experiences or what you have heard from others, rate your opinion of the following
aspects of VA care:
Extremely
Negative

Somewhat
Negative

Neutral

Somewhat
Positive

Extremely
Positive

1. Availability of emergency medical
services

2. Availability of primary care
services

3. Availability of family planning and birth
control services

4. Availability of female-specific care

5. Availability of mental health services

6. Ability to get a female or male doctor,
depending on your preference

7. Amount of privacy

8. Waiting times to get an appointment
for a regular check-up

9. Waiting time to get an appointment
when you’re really sick

10. Waiting times at the pharmacy

11. The amount of paperwork that needs
to be completed to receive care

12. Ability to get in touch with the medical
staff by phone

13. Coordination of care across services

14. Availability of parking

15. Convenience of location

16. Safety of the location

17. Accessibility by public transportation

18. Hours when the facility is open

19. The facility’s cleanliness

VA Form 10-0478
December 2009

-1-

OMB 2900-XXXX
Estimated Burden: 45 min.

20. Confidentiality of medical records

21. Staffs’ knowledge of women’s health
care needs

22. Staffs’ knowledge of health care
needs of Veterans from your cohort
(e.g., OEF/OIF veterans)

23. Staffs’ courtesy and respect toward
patients

24. Doctors’ skill and expertise

25. Staffs’ ability to speak your native
language

26. Staffs’ familiarity with Veterans’
unique health-care needs

27. Health-care providers’ attentiveness
during appointments

28. Health-care providers’ interest in your
thoughts and opinions about your
health care

To what extent do you agree or disagree with the following statements?
29. Work responsibilities make it difficult to get my health-care needs met.
___ Strongly Agree
___ Somewhat Agree
___ Neither Agree nor Disagree

___ Somewhat Disagree
___ Strongly Disagree
___ Not applicable

30. Childcare responsibilities make it difficult to get my health-care needs met.
___ Strongly Agree
___ Somewhat Agree
___ Neither Agree nor Disagree
31.

___ Somewhat Disagree
___ Strongly Disagree
___ Not applicable

How much would you say you know about your VA benefits? Would you say you know:
___ Everything you need to know
___ Most of what you need to know
___ Some of what you need to know
___ A little of what you need to know
___ Almost none of what you need to know about your veterans benefits

32. To your knowledge, how long does it or would it take you to travel to a VA facility to receive
care?
…………………………………………………………………………………………………………
1
2
3
4
5
6
7
< 15 min
16–30 min
31–45 min
46–60 min
61–90 min
> 91 min
Don’t Know
VA Form 10-0478
December 2009

-2-

OMB 2900-XXXX
Estimated Burden: 45 min.

33. How much does or would the cost of traveling to the VA interfere with receiving care?
…………………………………………………………………………………………………………
1
2
3
4
Not at all
A little
Moderately
A great deal
34. How much does or would traveling through dangerous areas interfere with receiving
VA health-care?
…………………………………………………………………………………………………………
1
2
3
4
Not at all
A little
Moderately
A great deal

Instructions: Please rate the extent to which you agree with the following statements about seeking
mental health care. Please note that you do not have to be currently experiencing, or ever have
experienced, a mental health problem to answer these questions.
For these, the term “mental health problems” is used to refer to psychological problems that one may
experience at different points in life, from more minor mental health problems such as temporary feelings
of depression to more serious mental health illnesses, including posttraumatic stress disorder (PTSD)
and substance use disorders.
The term “mental health care” refers to participating in therapy/counseling with a mental health provider
(for example, a social worker or a psychologist) or receiving psychiatric medications from a mental health
provider or a Primary Care Physician.
1. A problem would have to be really bad for me to seek mental health care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. I would feel uncomfortable seeing a mental health provider.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. If I had a mental health problem, I would prefer to deal with it myself rather than to
seek treatment.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. I would be unlikely to seek mental health treatment even if I was having a serious
mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

-3-

OMB 2900-XXXX
Estimated Burden: 45 min.

5. Most mental health problems can be dealt with without seeking professional help.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. My family or friends would encourage me to seek professional help if I was having
a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. I wouldn’t want to share personal information with a mental health provider.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
8. Seeing a mental health provider would make me feel weak.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
9. I would think less of myself if I were to seek mental health treatment.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
10. Leaders in my military unit encouraged service members who had mental health
problems to seek professional treatment.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
11. Most mental health problems get better without mental health treatment.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
12. If I were to seek mental health treatment, I would feel stupid that I couldn’t fix the
problem on my own.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
13. I have family members or friends who are knowledgeable about mental health
problems and how to treat them.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
VA Form 10-0478
December 2009

-4-

OMB 2900-XXXX
Estimated Burden: 45 min.

Instructions: Please rate the extent to which you agree with the following statements about mental
health problems.
1. Most people with mental health problems are violent or dangerous.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. It is a sign of weakness to have a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. Most people with mental health problems could get better if they really wanted to.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. People with mental health problems cannot be counted on.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. I have a hard time respecting people with mental health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. People with mental health problems often use their health problems as an excuse.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. Only people who are flawed to begin with suffer from mental health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
8. People with mental health problems can’t take care of themselves.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
9. Most people with mental health problems are just faking their symptoms.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
VA Form 10-0478
December 2009

-5-

OMB 2900-XXXX
Estimated Burden: 45 min.

10. I don’t feel comfortable around people with mental health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
11. It would be difficult to have a normal relationship with someone with mental
health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
12. People with mental health problems require too much attention.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
13. Most mental health problems are due to genetic factors resulting in a biochemical
imbalance or brain disease.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
14. Most mental health problems are due to difficult life circumstances, such as a trauma
or other stressful events.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
15. People experience mental health problems because of personal weaknesses.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
16. Which of the following causes do you believe best explains why people experience
mental health problems? (Mark only one)
___ Genetic factors resulting in a brain disease or biochemical imbalance
___ Experiencing difficult life circumstances, such as a trauma or other stressful event
___ Personal weaknesses that prevent people from handling stressful life events.
Either based on your own experiences or what you have heard from others, rate the extent to
which you agree with the following statements about mental health care.
1. I do not think that medication would help if I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
VA Form 10-0478
December 2009

-6-

OMB 2900-XXXX
Estimated Burden: 45 min.

2. Mental health treatment just makes things worse.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3

If I were to seek mental health care, I would be forced to undergo treatment that
I would not want.

1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. Mental health providers (for example, therapists or counselors) cannot be trusted.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. Mental health providers don’t really care about their patients.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. Mental health providers aren’t really interested in helping their patients get better.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. Mental health treatment generally does not work.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
8. Therapy or counseling does not really help for mental health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
9. I have family members or close friends who have found mental health
treatment helpful.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
10. Medications prescribed for mental health problems are addictive and therefore
should not be taken.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
VA Form 10-0478
December 2009

-7-

OMB 2900-XXXX
Estimated Burden: 45 min.

11. Medications prescribed for mental health problems have bad side effects that
outweigh their benefits.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
The next set of items refer to how people in your life would react *if* you were to have a mental health problem.
Please note that you do not need to have a current mental health problem to complete these questions.
Instructions: Please rate the extent to which you agree with the following statements about family and friend
relationships and mental health.
1. Friends and family would think less of me if they knew I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. Friends and family would be afraid that I might be violent or dangerous if they knew
I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. Friends and family would see me as weak if they knew I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. Friends and family would feel uncomfortable around me if they knew I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. Friends and family would think that I cannot be trusted if they knew I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. Friends and family would have less respect for me if they knew I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

-8-

OMB 2900-XXXX
Estimated Burden: 45 min.

7. Friends and family would think I was faking if they knew I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
Instructions: Please rate the extent to which you agree with the following statements about career implications
of mental health problems.
1. People at work would think I am not capable of doing my job if they knew I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. People at work would have less respect for me if it was known I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. An employer might give me less desirable work if I told them I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. My career/job options would be limited if it was known I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. Co-workers would feel uncomfortable around me if I told them I had a mental
health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. An employer might treat me unfairly if it was known that I had a mental health problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. My supervisor or co-workers would think I was faking if I told them I had a mental health
problem.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

-9-

OMB 2900-XXXX
Estimated Burden: 45 min.

Instructions: Please rate the extent to which you agree with the following statements about veterans who use VA.
For all items, the use of the term “VA health care” refers to the use of any and all health care services
within the VA system, including both medical and mental health care services, for either general health
care (example: annual physical exams) or for specific problems (example: treatment for a specific injury).
1. Most veterans who use the VA for health care have serious mental health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. Most veterans who use the VA for health care are poor.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. Most veterans who use the VA for health care are homeless.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. Most veterans who use the VA for health care exaggerate or fake their health problems.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. Most veterans who use the VA for health care are violent or dangerous.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. Most veterans who use the VA for health care are weak.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. My health-care needs are very different from most veterans who use the VA for
health care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
8 . I share similar health concerns with most VA users.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

- 10 -

OMB 2900-XXXX
Estimated Burden: 45 min.

9. My military experiences were very different from most veterans who use the VA
for health care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
10. Most VA health-care users have very different medical problems than I have.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
11. I don’t have a lot in common with most veterans who use the VA for health care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
12. Most veterans who use VA care are generally healthy.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
13. Most VA health-care users have more serious physical health problems than me.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
14. Most VA health-care users have more serious mental health problems than me.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
15. I don’t fit in within the VA health-care setting.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
Instructions: Please rate the extent to which you agree with the following statements about VA health care.
1. VA providers can be counted on to protect veterans’ private medical information.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. Using VA health care could jeopardize my ability to get or keep a job.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
VA Form 10-0478
December 2009

- 11 -

OMB 2900-XXXX
Estimated Burden: 45 min.

3. My medical information at the VA would be kept private/confidential.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. A current or potential employer (e.g., DoD, state police, civilian job) might be able to
access my VA medical records.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. Medical information at the VA is vulnerable to being accessed by “computer hackers.”
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. My spouse or partner might be told things about my VA medical care that I would not want
them to know.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
7. I’ve heard good things about the VA from friends or family members who use or have
used VA health care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
8. My personal VA medical information might get out to other veterans.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
9. VA health care providers who are not involved in my care might get access to my private
information.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
10. I’ve heard good things about the VA from other veterans who have used VA services.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

- 12 -

OMB 2900-XXXX
Estimated Burden: 45 min.

Instructions: Please rate the extent to which you agree with the following statements about VA health care.
1. VA health care services should be reserved for veterans who don’t have other
alternatives.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. I am just as deserving of VA health care services as other veterans.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
3. There are other veterans who need VA health care much more than I do.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. By using VA health care, I may take away resources from other veterans that need
them more than I do.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. I have as much right to use the VA for health care as other veterans.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
6. My health problems aren’t serious enough to seek VA care.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
Instructions: Please rate the extent to which you agree with the following statements.
1. Being a veteran is a very important part of who I am.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
2. I like it when people know that I am a veteran.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree

VA Form 10-0478
December 2009

- 13 -

OMB 2900-XXXX
Estimated Burden: 45 min.

3. I am proud to be a veteran.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
4. I spend most of my time with other veterans.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
5. I relate best to other veterans.
1 ................................... 2..................................3 ...................................4 .........................5
Strongly
Somewhat
Neither agree
Somewhat
Strongly
disagree
disagree
nor disagree
agree
agree
The following questions address significant life events that you may have experienced. Indicate
how many times, if any, you have experienced each event.
1. Have you ever experienced a natural disaster (a flood, hurricane, earthquake, etc.)?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times_____
2. Were you involved in a motor vehicle accident for which you received medical attention or
that badly injured or killed someone?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
3. Have you been involved in any other kind of accident where you or someone else was badly hurt?
(examples: a plane crash, a drowning or near drowning, an electrical or machinery accident, an
explosion, home fire, chemical leak, or overexposure to radiation or toxic chemicals)
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
4. Have you ever exposed to warfare or combat? (for example: in the vicinity of a rocket
attack or people being fired upon; seeing someone getting wounded or killed)
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
5. Have you experienced the unexpected and sudden death of a close friend or loved one?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
6. Have you been robbed or witnessed a robbery, where the robber(s) used or displayed a weapon?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
7. Have you ever been hit or beaten up and badly hurt by a stranger or someone you didn’t know
very well?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
8. Have you seen a stranger (or someone didn’t know very well) attack or beat up another person and
seriously injure or kill them?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
VA Form 10-0478
December 2009

- 14 -

OMB 2900-XXXX
Estimated Burden: 45 min.

9. Has anyone threatened to kill you or cause you serious physical harm?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
10. While growing up: Were you physically punished in a way that resulted in bruises, burns, cuts, or
broken bones?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
11. While growing up: Did you witness family violence? (such as your father hitting your mother; or any
family member beating up or inflicting bruises, burns or cuts on another family member)
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
12. Have you ever been slapped, punched, kicked, beaten up, or otherwise physically hurt by your spouse
(or former spouse), a boyfriend/girlfriend, or some other intimate partner?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
13. Before your 13th birthday: Did anyone who was at least 5 years older than you touch or fondle your
body in a sexual way or make you touch or fondle their body in a sexual way?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
14. Before your 13th birthday: Did anyone close to your age touch sexual parts of your body or make you
touch sexual parts of their body against your will or without your consent?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
15. After your 13th birthday and before your 18th birthday: Did anyone touch sexual parts of your body or
make you touch sexual parts of their body—against your will or without your consent?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
16. After your 18th birthday: Did anyone touch sexual parts of your body or make you touch sexual parts
of their body-against your will or without your consent?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
17. Has anyone stalked you—in other words: followed you or kept track of your activities—causing you to
feel intimidated or concerned for your safety?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
18. Have you or a loved one ever had a life threatening illness?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
19. [For women:] Have you ever had a miscarriage?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
20. [For women:] Have you ever had an abortion?
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
21. Have you experienced (or witnessed) any other events that were life threatening, caused serious
injury, or were highly disturbing or distressing? (examples: being kidnapped or held hostage; lost in the
wilderness; violent death of a pet; a serious animal bite; permanent physical injury to a loved one)
never____ once _____ twice _____ 3 times____ 4 times____ 5 times____ more than 5 times _____
VA Form 10-0478
December 2009

- 15 -

OMB 2900-XXXX
Estimated Burden: 45 min.

The statements below are about your combat experiences during deployment. As used in these
statements, the term “unit” refers to those you lived and worked with on a daily basis during
deployment. Describe how often you experienced each circumstance by circling the number that best
fits your choice.
A few Daily or
A few times A few
Never over entire times each times almost
each
deployment month
daily
week

While deployed:
1. I went on combat patrols or missions.

2. I encountered land or water mines, booby traps, or roadside
bombs (for example, IEDs).

3. My unit received hostile incoming fire.

4. My unit received "friendly" incoming fire.

7. I took part in an assault on entrenched or fortified positions.

8. I took part in an invasion that involved naval or land forces.

9. My unit suffered casualties.

5. I was in a vehicle (for example, a “humvee,” helicopter, or
boat) or part of a convoy that was attacked.
6. I was part of a land or naval artillery unit that fired on enemy
combatants.

10. I personally witnessed someone from my unit or an ally unit
being seriously wounded or killed.
11. I personally witnessed enemy combatants being seriously
wounded or killed.
12. I personally witnessed civilians (for example, women and
children) being seriously wounded or killed.

13. I was wounded in combat.

14. I fired my weapon at enemy combatants.

15. I wounded or think I wounded someone during combat
operations.

16. I killed or think I killed someone during combat operations.

17. I was involved in locating or disarming explosive devices.

20. I participated in hand-to-hand combat.

21. I experienced a “close call” or attack by an enemy combatant
(for example, an insurgent).

22. I was involved in searching and/or disarming civilians.

18. I was involved in searching or clearing homes, buildings, or
other locations.
19. A unit member I knew went missing in action or was taken
prisoner/hostage.

VA Form 10-0478
December 2009

- 16 -

OMB 2900-XXXX
Estimated Burden: 45 min.

The next set of questions is again about your relationships with other military personnel while
deployed. Describe how often you experienced each circumstance by circling the number that best fits
your choice.
While I was deployed, military leaders or other service members:

Never

Once or Several
twice
times

Many
times

1. ...spread negative rumors about my sexual activities.

2. ...made crude and offensive sexual remarks directed at me, either
publicly or privately.

3. ...pressured me into unwanted sexual activity.

4. ...offered me some sort of reward or special treatment to take part in
sexual behavior.
5. ...threatened me with some sort of retaliation for not being sexually
cooperative (for example, the threat of a negative review or physical
violence).
6. ...made unwanted attempts to stroke or fondle me (for example,
stroking my leg or neck).

7. ...made unwanted attempts to have sex with me.

8. ...forced me to have sex.

The following questions ask about your current health. Circle the response corresponding to the most appropriate option.
1) In general, would you say your health is:

Good

Fair

Poor

2) Does your health now limit you in
moderate activities, such as moving a
table, pushing a vacuum cleaner,
bowling or playing golf?

No, not
limited at
all

Yes,
limited
a little

Yes,
limited
a lot

3) Does your health now limit you in
climbing several flights of stairs?

No, not
limited at
all

Yes,
limited
a little

Yes,
limited
a lot

4) In the past four weeks, have you
accomplished less than you would like as
a result of your physical health?

Yes

5) In the past four weeks, have you been
limited in your work or other activities as
a result of your physical health?

Yes

6) In the past four weeks, have you
accomplished less than you would like as
a result of any emotional problems (such
as feeling depressed or anxious)?

Yes

7) In the past four weeks, have you not
done work or other activities as carefully
as usual as a result of any emotional
problems?

Yes

VA Form 10-0478
December 2009

Excellent Very good

- 17 -

OMB 2900-XXXX
Estimated Burden: 45 min.

8) During the past four weeks, how much
did pain interfere with your normal work
(including both work outside the home
and housework)?
How much of the time during the past
four weeks…

Not at all

A
little bit

Moderately

None of A little of Some of the A good bit
the time the time
time
of the time

Quite
a bit

Extremely

Most of
the time

All of the
time

9) …have you felt calm and peaceful?

10) ...did you have a lot of energy?

11) …have you felt downhearted and blue?

12) …has your physical health or emotional
problems interfered with your social
activities (like visiting with friends,
relatives, etc.?)

None of the time

A little of the Some of Most of the All of the
time
the time
time
time

The following is a list of conditions you may have experienced before and/or after your deployment.
Indicate whether or not you have been told BY A HEALTH CARE PROFESSIONAL that you had a
particular condition, and if you have, when you were told. Circle the number corresponding to each
response that applies.

I have been told by a healthcare
professional that I was suffering from…

Before most recent After most recent
deployment
deployment

Within past 3
months

1) Heart disease

No / Yes

2) Chronic back pain

No / Yes

3) Spinal cord injury

No / Yes

4) Hypertension or high blood
Pressure

No / Yes

5) Diabetes or high blood sugar

No / Yes

6) Allergic rhinitis (inflammation of the nose
or its mucous membranes)

No / Yes

7) Arthritis or degenerative joint disease

No / Yes

8) Chronic gastrointestinal problems
(examples: irritable colon, colitis)

No / Yes

9) Dyspnea (difficulty breathing)

No / Yes

10) Chronic sinusitis (severe sinus
problems)

No / Yes

11) Depression

No / Yes

12) Posttraumatic Stress Disorder (PTSD)
13) Any other anxiety disorder other than
PTSD (for example, panic disorder,
generalized anxiety disorder)

No / Yes

VA Form 10-0478
December 2009

- 18 -

OMB 2900-XXXX
Estimated Burden: 45 min.

I have been told by a healthcare
professional that I was suffering from…

Within past 3
months

Before most recent After most recent
deployment
deployment

14) Chronic Fatigue Syndrome

No / Yes

15) Asthma or bronchitis

No / Yes

16) Fibromyalgia or fibrositis (fatigue of
muscles, muscle pain, joint pain,
tenderness at specific points of body)

No / Yes

17) Migraines

No / Yes

18) Amnesia or severe memory loss

No / Yes

19) Sleep apnea or narcolepsy

No / Yes

20) Thyroid problem (examples:
hypothyroidism or hyperthyroidism)

No / Yes

21) Cancer

No / Yes

22) Any other health condition not listed:
Fill in the blank with condition.

No / Yes

The following statements refer to feelings you may have had since returning from your most recent
deployment. Think about the event or events that were most disturbing to you while you were
deployed and respond to the statements about experiences or feelings you have had in the PAST
THREE MONTHS. Circle the number that best fits your choice.
In the past three months I have been
bothered by...
1) ...repeated, disturbing memories of my
military experiences.
2) ...repeated, disturbing dreams of my
military experiences.
3) ...suddenly acting or feeling as if my
military experiences were happening
again.
4) ...feeling very upset when something
happened that reminded me of my
military experiences.
5) ...trouble remembering important parts of
my military experiences.
6) ...loss of interest in activities that I used
to enjoy.
VA Form 10-0478
December 2009

Not at all

A little
bit

Moderately

Quite a
bit

Extremely

- 19 -

OMB 2900-XXXX
Estimated Burden: 45 min.

Not at all

A little
bit

Moderately

Quite a
bit

Extremely

14) ...feeling jumpy or easily startled.

15) ...having physical reactions when
something reminds me of my military
experiences.

In the past three months I have been
bothered by...
7) ...feeling distant or cut off from other
people.
8) ...feeling emotionally numb, or being
unable to have loving feelings for those
close to me.
9) ...feeling as if my future will somehow be
cut short.
10) ...trouble falling or staying asleep.
11) ...feeling irritable or having angry
outbursts.
12) ...having difficulty concentrating.
13) ...being “super alert,” or watchful or on
guard.

In the PAST THREE MONTHS, I have
tried to:

16) ...avoid thinking about my military
experiences, or avoid having feelings
about them.
17) ...avoid activities or situations because
they reminded me of my military
experiences.

Next is a set of statements about feelings you may or may not have experienced IN THE PAST THREE
MONTHS. Read each statement and indicate the extent to which you agree or disagree with each
statement by circling the number corresponding to your response choice.
Strongly
disagree
In the past three months...

Neither
Somewhat
Somewhat
agree nor
agree
disagree
disagree

Strongly
agree

1) ...I have felt sad.

2) ...I have felt discouraged about the future.

3) ...I have felt like a failure.

4) ...I haven’t gotten as much satisfaction
out of things as I used to.

5) ...I have been disappointed in myself.

6) ...I have been critical of myself for my
weaknesses or mistakes.

VA Form 10-0478
December 2009

- 20 -

OMB 2900-XXXX
Estimated Burden: 45 min.

Strongly
disagree
In the past three months...
7) ...I have had thoughts about killing myself.

Neither
Somewhat
Somewhat
agree nor
disagree
agree
disagree
2

Strongly
agree

The following questions relate to your use of alcohol before and/or after returning from your
deployment. For the first four items, circle the number corresponding to EACH response that applies.
No

Yes, before I
was deployed

Yes, at some
time after
deployment

Yes, in the
last 3
months

1) Have you felt you ought to cut down on
drinking?

2) Have people criticized your drinking?

5) In the past three months how often have
you had a drink containing alcohol?

Never

Monthly or
less

6) In the past three months, how many drinks
containing alcohol have you had on a
typical day when you were drinking?

None

1 or 2

3) Have you felt bad or guilty about your
drinking?
4) Have you had a drink first thing in the
morning to steady your nerves or get rid of
a hangover (an “eye-opener”)?

2 to 4 5 or more
2 to 4 times
times a times a
a month
week
week
3 or 4

5 or 6

The following questions relate to injuries you may have experienced during your most
recent deployment.
1. Did you have any injury(ies) during your most recent deployment from any of the following?
(Mark all that apply.)
___ Fragment
___ Bullet
___ Vehicular (any type of vehicle, including airplane)
___ Blast (for example, Improvised Explosive Device, RPG, Land mine, Grenade, etc.)
___ Fall
1a. If you had an injury, what was the date of the most serious injury? __________
2. Did any injury received while you were deployed result in any of the following?
(Mark all that apply.)
___ Being dazed, confused or “seeing stars”
___ Not remembering the injury
___ Losing consciousness (knocked out) for less than a minute
___ Losing consciousness for 1-30 minutes
___ Losing consciousness for longer than 30 minutes
VA Form 10-0478
December 2009

- 21 -

7 or more

OMB 2900-XXXX
Estimated Burden: 45 min.

___ Symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)
___ Head Injury
___ None of the above
3. Did you have or have you had any of the following symptoms from injuries noted in #1?
(Mark all that apply.)
Right After
Injury?

Was the Symptom
a Problem before
Injury?

Now?

If a problem before,
did symptom worsen
after injury?

a. Headaches
b. Dizziness
c. Memory problems
d. Balance problems
e. Ringing in the ears
f. Irritability
g. Sleep problems
h. Other; specify:
The following questions relate to your health benefits and your use of health care.
1. Do you receive disability benefits? (Mark all that apply.)
___ Yes, Disability payments from the VA

___ Yes, Disability Insurance from employer

___ Yes, SSI

___ Yes, Self-purchased disability insurance

___ Yes, SSDI

___ Yes, I get disability payments, but not sure
oooowhere they come from

___ Yes, Worker’s compensation

___ No, I don’t receive any disability payments

2. Have you ever applied or are you currently applying for service-connected disability status
from the VA?
___ Yes

___ No

2a. (If yes in past) Did you receive service-connected disability status?
___ Yes

___ No

2b. If yes, What is the total % disability rating you received? ___
2c. What % disability rating did you receive for disability related to your mental health? ____
2d. What % disability rating did you receive for disability related to your physical health? ___
3. Do you currently have physical health problems that require health care?
___ Yes
___ No
___ Don’t know
VA Form 10-0478
December 2009

- 22 -

OMB 2900-XXXX
Estimated Burden: 45 min.

4. Do you currently have mental health problems that require health care?
___ Yes

___ No

___ Don’t know

5. Medicare is a health insurance program for people 65 years and older and people under age
65 who have certain disabilities. Are you currently covered by the Medicare program?
___ Yes

___ No

___ Don’t know

6. Some people who are eligible for Medicare have additional health insurance coverage through
a private insurance company. This is sometimes referred to as Medigap or Medicare
Supplement, and it is different from insurance you might have through an employer or former
employer. Are you currently covered by a Medigap or Medicare Supplement health insurance
plan?
___ Yes

___ No

___ Don’t know

7. Medicaid/Medi-Cal is a program that pays for health care for persons in need. It is different
from Medicare, the program for persons 65 and older and persons under 65 with certain
disabilities. Are you currently covered by Medicaid/Medi-Cal?
___ Yes

___ No

___ Don’t know

8. Are you currently covered by CHAMPUS or TRICARE?
___ Yes

___ No

___ Don’t know

9. Excluding VA health care benefits and Federal employee health benefits, are you currently
covered by any other government-provided health insurance or health service plan? For
example, Indian Health Service or military health care?
___ Yes

___ No

___ Don’t know

10. Excluding programs named above, are you currently covered by private health insurance that
you or someone else provides for you? For example, private insurance from an employer or
union, Federal employee health benefits, or private insurance that someone bought directly
from an insurance company? (Include plans obtained through someone who does not live in your
household. Do not include plans provided by military employers.)
___ Yes

VA Form 10-0478
December 2009

___ No

___ Don’t know

- 23 -

OMB 2900-XXXX
Estimated Burden: 45 min.

11. In the PAST YEAR, did you receive the following types of care, either at a VA or non-VA
Medical facility? Note that “inpatient care” refers to care that involves being admitted overnight
at a medical facility and “outpatient care” refers to care received during the day.
(Write numbers in all boxes that apply.)
# of times you
received this
care at a VA
facility

a. outpatient medical care visits for routine
exams, medical tests, shots, etc.
b. emergency room visit for medical problem

# of times you received
this care from a doctor,
hospital, or medical facility
outside of the VA

c. inpatient medical care (treatment requiring an
overnight stay in a hospital or residential
care facility)
d. outpatient mental health care (examples:
counseling, therapy)
e. emergency room visit for mental health care
f. inpatient mental health care (mental health
treatment requiring an overnight stay in a
hospital or residential care facility)
g. inpatient care for alcohol abuse or detox
h. inpatient care for drug abuse or detox
i. outpatient care visits for alcohol abuse
(examples: counseling, therapy)
j. outpatient care visits for drug abuse,
excluding methadone clinic (examples:
counseling, therapy)
k. methadone clinic visits
l. dental care visits
m. different medications prescriptions received,
excluding refills
12. How likely would you be to seek VA physical health care if you needed treatment in the
future?
___ Definitely would not
___ Probably would not

___ Probably would
___ Definitely would

13. How likely would you be to seek VA mental health care if you needed treatment in the
future?
___ Definitely would not
___ Probably would not
VA Form 10-0478
December 2009

___ Probably would
___ Definitely would

- 24 -

OMB 2900-XXXX
Estimated Burden: 45 min.

Listed below are a number of statements about how you think and do things. Please read each
statement and decide how true or false it is for you, personally. Circle the number that
corresponds to your response.
Very false

Somewhat
false

1) I'm always willing to admit it
when I make a mistake.

2) No matter whom I'm talking to, I'm
always a good listener.

3) I am always courteous, even to
people who are disagreeable.

4) It is sometimes hard for me to go on
with my work if I am not encouraged.

5) I sometimes feel resentful
when I don’t get my way.

6) On a few occasions, I have given up
doing something because I thought
too little of my ability.

7) There have been times when I felt
like rebelling against people in
authority even though I knew they
were right.
8) There have been occasions when I
took advantage of someone.
9) I sometimes try to get even rather
than forgive and forget.
10) I have never been irked when
people expressed ideas very
different from my own.
11) There have been times when I was
quite jealous of the good fortune of
others.
12) I am sometimes irritated by people
who ask favors of me.
13) I have never deliberately said
something that hurt someone’s
feelings.

Neither true
Somewhat true
nor false

Please mark the appropriate response or fill in the required information.
1. What is your gender?
___ Male

___ Female

2. What is your age? ____
VA Form 10-0478
December 2009

- 25 -

Very true

OMB 2900-XXXX
Estimated Burden: 45 min.

3. Are you of Hispanic or Latino origin or descent?
___ Yes, Hispanic
___ No, not Hispanic or Latino
4. In which of the following categories do you feel that you belong? (Mark all that apply.)
___ Pacific Islander or Native Hawaiian
___ Black or African/American
___ American Indian or Alaskan Native
___ White/Caucasian
___ Asian
___ Other (Specify) _________________
5. What is the highest level of education you have attained?
___ 8th grade or less
___ Some college
___ Some high school
___ Four-year college graduate
___ High school graduate
___ Some graduate or professional school
___ Vocational or technical training
___ Graduate or professional degree
6. What is your current marital status? (Mark all that apply.)
___ Married/Living with Partner
___ Widowed
___ Separated
___ Never married, in a long-term relationship
___ Divorced
___ Never married, not in a long-term
relationship
7. Do you have any children?
___ Yes
___ No
7a. If Yes, how many children do you have between the age of:
___ 0-3 yrs
___ 12-17 yrs
___ 4-6 yrs
___ 18 yrs or older
___ 7-11 yrs
8. Who do you live with? (Mark all that apply.)
___ My husband, wife or partner

___ Other relatives

___ My children

___ Other people who are not related to me

___ My parents or in-laws

___ No one else; I live alone

9. Are you currently… (Mark all that apply.)
___ Working for pay full –time (>30 hours/week)
___ Working for pay part –time (<30hours/week)
___ Working as a volunteer (no pay)
___ Student in a high school, job training, or college degree program
___ Homemaker
___ Not working but actively looking for work
___ Not working and not looking for work
___ Retired
___ Unable to work

VA Form 10-0478
December 2009

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OMB 2900-XXXX
Estimated Burden: 45 min.

10. Which of the following categories best describes your 2010 household income before taxes?
___ $15,000 or less

___ $50,001 to $75,000

___ $15,001 to $25,000

___ $75,001 to $100,000

___ $25,001 to $35,000

___ Over $100,000

___ $35,001 to $50,000
11. Are you currently serving in the military either on active duty or with the National Guard
or Reserves?
___ Yes (if yes, are you currently):
___ Active duty
___ National Guard
12.

___ No
___ Reserves

How long have you served in the military?
___ less than 1 year
___ 1-2 years
___ 3-4 years

___ 5-10 years
___ over 10 years

13. How long has it been since you returned from your most recent deployment?
___ less than 3 months
___ 3-5 months
___ 6-9 months

___ 10-12 months
___ More than 12 months

14. During what time period was your most recent deployment?
From ____/____/____ (month/day/year)

To ____/____/____ (month/day/year)

14a. Are you anticipating another deployment within the next year?
___ Yes
___ No
14b. How many times, in total, have you been deployed in support of OEF or OIF? ___
15. During your most recent deployment, were you deployed from:
___ Active duty
___ National Guard
___ Reserves
16. What was your branch of the military when you were deployed?
Marines____
Army____
Navy____
Air Force____
Coast Guard ____
17. What was your military rank when you were deployed (e.g., E-5, O-6)? _____________
18. What was your primary military occupation (MOS, SSI, Rating or NEC, NOBC, or AFSC)
when you were deployed? _____________
19. How would you describe your primary role during this deployment?
___ Combat arms
VA Form 10-0478
December 2009

___ Combat-support
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___ Service-support

OMB 2900-XXXX
Estimated Burden: 45 min.

20. Where were you stationed?
___________________________________________________________________________
21. If you are no longer in the military, did you receive an honorable discharge from the military?
___ Yes

___ N0

22. Pior to your most recent deployment to Iraq or Afghanistan, did you ever serve in any of the
following operations? (Mark all that apply)
___Vietnam

___Croatia-Bosnia (Provide Promise)

___Grenada

___Macedonia (Able Sentry)

___Lebanon

___Haiti (Restore Democracy)

___Panama (Operation Just Cause)

___Somalia (Restore Hope)

___Rwanda (Support Hope)

___Persian Gulf (Operation Desert Storm/Shield)

___Bosnia-Herzegovinia (Operation Joint Endeavor/Guard)
23. We may be doing a follow-up study in the future. May we contact you again to ask if you
would be interested in participating?
____Yes
____No

VA Form 10-0478
December 2009

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File Type	application/pdf
File Title	The Gulf War Experiences Project
Author	Brian N. Smith
File Modified	2010-02-22
File Created	2010-02-19