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pdf9738390863
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PRIVACY ACT STATEMENT: You have rights under the Privacy Act. The following statement describes how that Act applies to
this study:
Authority: Authority to request this information is granted under Title 5, U.S. Code 136, Department of Defense Regulations,
Executive Order 9396, DoD RCS#DD-HA(AR)2106 (expires 01/31/13), and OMB #0720-0029 (expires ??). Personal identifiers will
be used to link survey data with medical and other military records.
Purpose: Medical research information will be collected in a research project titled "Prospective Studies of U.S. Military Forces:
The Millennium Cohort Study." The project objective is to enhance basic medical knowledge and to improve the treatment and
prevention of illnesses that may be related to military service.
Routine Uses: The information provided in this questionnaire will be maintained in data files at the DoD Center for Deployment
Health Research at the Naval Health Research Center and used only for medical research purposes. Use of these data may be
granted to other federal and non-federal medical research agencies as approved by the Naval Health Research Center's
Institutional Review Board. However, your personal identifiers will be protected. By signing the original consent form, you
volunteered to disclose your information as identified above. If you do not agree to this disclosure, your failure will make the
research less useful. The "Blanket Routine Uses" that appears at the beginning of the Department of Defense's compilation of
medical databases also applies to this system.
Anonymity: All responses will be held in confidence by the DoD Center for Deployment Health Research. Information you provide
will be considered only when statistically summarized with the responses of others. Your personal identifiers (name, etc.) will only
be used to link data sets and then the identifiers will be stripped from study data such that medical researchers cannot identify you
individually.
Voluntary Disclosure: Completion of the questionnaire is voluntary. Failure to respond to any of the questions will NOT result in
any penalties except possible lack of representation of your views in the final results and outcomes.
PUBLIC BURDEN STATEMENT: Public reporting burden for this collection of information is estimated at 30 minutes. Comments
on the burden or content of the instrument should be sent to the Millennium Cohort Study team, PO Box 85777, San Diego, CA
92186-5777. Under 5 CFR 1320.5(b), an Agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless the collection displays a valid control number.
Page 1
4215390868
You may also complete this questionnaire online at
www.MillenniumCohort.org
MARKING INSTRUCTIONS
• Use BLACK or BLUE ink.
• Shade circles like this:
• Mistakes must be crossed out with an "X".
• Print in CAPITAL LETTERS and avoid contact with the edge of the box. EXAMPLE:
A B C D E F G H
I
J K L M N O P Q R S T U V W X Y Z
• Answer each question to the best of your ability.
• It will take approximately 30 minutes to complete the questionnaire.
1. What is your current mailing address?
Address Line 1:
Address Line 2
(optional):
City (or FPO/APO):
State/Province/Region
(or AA/AE/AP):
ZIP/Postal Code:
Country:
2. Please provide your daytime phone number:
3. Please provide your email address:
If any of your contact information changes, please log on to www.MillenniumCohort.org
or call our toll-free number at (888) 942-5222 to provide an update.
4. What year were you born?
1
9
M
6. What is today's date?
5. What are the last four digits of your
Social Security number?
M
D D
/
/
Y
Y
2
0
Y
Page 2
Y
6001390863
7. What is your current marital status?
Choose the single best answer.
8. What is the highest level of education that you
have completed?
Choose the single best answer.
Single, never married
9. Which hand do you use
for writing?
Right
Less than high school completion/diploma
Now married
High school degree/GED/or equivalent
Left
Separated
Some college, no degree
Use both equally
Divorced
Associate's degree
Widowed
Bachelor's degree
Master's, doctorate, or professional degree
10. How tall are you?
For example, a person who is 5'8"
tall should write 5 feet 08 inches.
feet
inches
11. What is your current weight?
pounds
12. How much did you weigh a year ago?
pounds
If you are FEMALE, please continue to question 13
If you are MALE, please skip to question 14 on page 4
13. FOR WOMEN ONLY:
a. Have you had at least one menstrual period in the past 12 months?
No
Yes
b. If NO: What is the reason that you have not had a menstrual period in the past 12 months?
Mark all that apply.
Pregnancy and/or breast feeding
Hysterectomy
Contraception or hormone therapy
Other
Menopause
Unknown
please specify
No
c. During the week before your period starts, do you have a serious problem
with your mood - like depression, anxiety, irritability, anger, or mood swings?
d. If YES: Do these problems go away by the end of your period?
e. Are you currently pregnant?
f.
Have you given birth within the last 3 years?
g. Have you ever been diagnosed with gestational diabetes by a glucose tolerance test
during pregnancy?
h. Have you had a miscarriage within the last 3 years?
i.
During the last 3 years, have you tried and been unable to become pregnant?
Page 3
Yes
Does
not apply
1073390867
14. In the last 3 years, has your doctor or other health professional told
you that you have any of the following conditions?
If YES, in what
year were you
first diagnosed?
Mark here if you
were hospitalized
for the condition in
the last 3 years
a. Hypertension (high blood pressure)
No
Yes
Hospitalized
b. High cholesterol requiring medication
No
Yes
Hospitalized
c. Coronary heart disease
No
Yes
Hospitalized
d. Heart attack
No
Yes
Hospitalized
e. Angina (chest pain)
No
Yes
Hospitalized
No
Yes
Hospitalized
g. Sinusitis
No
Yes
Hospitalized
h. Chronic bronchitis
No
Yes
Hospitalized
i.
Emphysema
No
Yes
Hospitalized
j.
Asthma
No
Yes
Hospitalized
k. Kidney failure requiring dialysis
No
Yes
Hospitalized
l.
No
Yes
Hospitalized
m. Pancreatitis
No
Yes
Hospitalized
n. Diabetes or sugar diabetes
No
Yes
Hospitalized
o. Gallstones
No
Yes
Hospitalized
p. Kidney stones
No
Yes
Hospitalized
q. Hepatitis B
No
Yes
Hospitalized
r.
No
Yes
Hospitalized
s. Any other hepatitis
No
Yes
Hospitalized
t.
Cirrhosis
No
Yes
Hospitalized
u. Fibromyalgia
No
Yes
Hospitalized
v. Rheumatoid arthritis
No
Yes
Hospitalized
w. Lupus
No
Yes
Hospitalized
f.
Any other heart condition
please specify
Bladder infection
Hepatitis C
Question 14 continued on page 5...
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0565390862
Question 14 continued from previous page
14. In the last 3 years, has your doctor or other health professional told
you that you have any of the following conditions?
If YES, in what
year were you
first diagnosed?
Mark here if you
were hospitalized
for the condition in
the last 3 years
x. Multiple sclerosis
No
Yes
Hospitalized
y. Crohn's disease
No
Yes
Hospitalized
z. Stomach, duodenal, or peptic ulcer
No
Yes
Hospitalized
aa. Ulcerative colitis or proctitis
No
Yes
Hospitalized
bb. Acid reflux / gastroesophageal reflux disease
requiring medication
No
Yes
Hospitalized
cc. Significant hearing loss
No
Yes
Hospitalized
dd. Significant vision loss even with glasses or contact lenses
No
Yes
Hospitalized
ee. Tinnitus / ringing of the ears
No
Yes
Hospitalized
ff. Migraine headaches
No
Yes
Hospitalized
gg. Stroke
No
Yes
Hospitalized
hh. Neuropathy-caused reduced sensation in hands or feet
No
Yes
Hospitalized
ii. Seizures
No
Yes
Hospitalized
jj. Sleep apnea
No
Yes
Hospitalized
kk. Anemia
No
Yes
Hospitalized
ll. Thyroid condition other than cancer
No
Yes
Hospitalized
No
Yes
Hospitalized
nn. Chronic fatigue syndrome
No
Yes
Hospitalized
oo. Depression
No
Yes
Hospitalized
pp. Schizophrenia or psychosis
No
Yes
Hospitalized
qq. Manic-depressive disorder
No
Yes
Hospitalized
rr. Posttraumatic stress disorder
No
Yes
Hospitalized
ss. Infertility
No
Yes
Hospitalized
No
Yes
Hospitalized
mm. Cancer
please specify
tt. Other
please specify
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1889390862
15. In the last 3 years, have you had persistent or recurring problems with any of the following?
a. Severe headache
No
Yes
k. Night sweats
No
Yes
b. Diarrhea
No
Yes
l.
No
Yes
c. Rash or skin ulcer
No
Yes
m. Unusual muscle pains
No
Yes
d. Sore throat
No
Yes
n. Shortness of breath
No
Yes
e. Frequent bladder infections
No
Yes
o. Trouble sleeping
No
Yes
f.
No
Yes
p. Unusual fatigue
No
Yes
g. Fever
No
Yes
q. Forgetfulness
No
Yes
h. Sudden unexplained hair loss
No
Yes
r.
No
Yes
i.
Earlobe pain
No
Yes
s. Other
No
Yes
j.
Sleepy all the time
No
Yes
Cough
Chest pain
Confusion
please specify
16. Over the past 3 years, approximately how many days were you hospitalized because of illness or injury?
(exclude hospitalization for pregnancy and childbirth)
None
1 day
2-5 days
6-10 days
11-15 days
16-20 days
21 days or more
17. Over the past 3 years, approximately how many days were you unable to work or perform your usual activities
because of illness or injury? (exclude lost time for pregnancy and childbirth)
None
1 day
2-5 days
6-10 days
11-15 days
16-20 days
18. During the last 4 weeks, how much have you been
bothered by any of the following problems?
Not bothered
a. Stomach pain
b. Back pain
c. Pain in your arms, legs, or joints (knees, hips, etc)
d. Pain or problems during sexual intercourse
e. Headaches
f.
Chest pain
g. Dizziness
h. Fainting spells
i.
Feeling your heart pound or race
j.
Shortness of breath
k. Constipation, loose bowels, or diarrhea
l.
Nausea, gas, or indigestion
m. Ringing in the ears
n. Difficulty with balance
o. Women only: menstrual cramps or other problems with your periods
Page 6
21 days or more
Bothered
a little
Bothered
a lot
5909390869
19. Over the last 2 weeks, how often have you been bothered by any of
the following problems?
Not at all
Several
days
More than
half the
days
Nearly
every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f.
Feeling bad about yourself - or that you are a failure or have
let yourself or your family down
g. Trouble concentrating on things, such as reading the newspaper
or watching television
h. Moving or speaking so slowly that other people could have noticed,
or the opposite - being so fidgety or restless that you have been
moving around a lot more than usual
If you have been bothered by any of the items listed above on this page,
you may want to seek help from a health professional in your area.
20.
No
Yes
b. Has this ever happened to you before?
No
Yes
c. Do some of these attacks come suddenly out of the blue - that is, in
situations where you don't expect to be nervous or uncomfortable?
No
Yes
d. Do these attacks bother you a lot, or are you worried about having another attack?
No
Yes
a. Were you short of breath?
No
Yes
b. Did your heart race, pound, or skip?
No
Yes
c. Did you have chest pain or pressure?
No
Yes
d. Did you sweat?
No
Yes
e. Did you feel as if you were choking?
No
Yes
f.
No
Yes
g. Did you have nausea or an upset stomach, or the feeling that you were
going to have diarrhea?
No
Yes
h. Did you feel dizzy, unsteady, or faint?
No
Yes
i.
Did you have tingling or numbness in parts of your body?
No
Yes
j.
Did you tremble or shake?
No
Yes
No
Yes
a. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic?
If you marked NO, please skip to question 22 on page 8
21. Think about your last bad anxiety attack.
Did you have hot flashes or chills?
k. Were you afraid you were dying?
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PAGE STARTS HERE
22. Over the last 4 weeks, how often have you been bothered by any of the
following problems?
Not
at all
More
than half
the days
Several
days
a. Feeling nervous, anxious, on edge, or worrying a lot
about different things
If you marked NOT AT ALL, skip to question 23
b. Feeling restless so that it is hard to sit still
c. Getting tired very easily
d. Muscle tension, aches, or soreness
e. Trouble falling asleep or staying asleep
f.
Trouble concentrating on things, such as reading a book or
watching TV
g. Becoming easily annoyed or irritable
23. On an average day, how many 8-12 oz beverages containing caffeine do you drink (such as coffee, tea, soda)?
None
1-2 per day
3-5 per day
6-10 per day
11 or more per day
24. About how many times each week do you eat from a fast food restaurant (such as hamburgers, tacos, or pizza)?
None
Once a week
2-3 times/week
4-7 times/week
8-14 times/week
25. a. Do you often feel that you can't control what or how much you eat?
15 or more times/week
No
Yes
b. Do you often eat, within any 2 hour period, what most people would regard as
an unusually large amount of food?
No
Yes
c. If you marked YES to either of the above, has this been as often, on
average, as twice a week for the LAST 3 MONTHS?
No
Yes
a. Made yourself vomit?
No
Yes
b. Took more than twice the recommended dose of laxatives?
No
Yes
c. Fasted - not eaten anything at all for at least 24 hours?
No
Yes
d. Exercised for more than an hour specifically to avoid gaining weight after binge eating?
No
Yes
e. If you marked YES to any of these ways of avoiding gaining weight, were any as
often, on average, as twice a week?
No
Yes
26. In the last 3 months, have you done any of the following in order to avoid gaining weight?
27. Have you and a partner ever tried to
get pregnant?
No
Yes
Not applicable
29. a. If you and a partner ever got
pregnant, did you have a
miscarriage?
Does not apply (no pregnancy)
If you marked No or Not applicable,
skip to question 29
28. If YES, have you and a partner ever been
unsuccessful getting pregnant for a year
or more (not including time spent apart,
such as deployment)?
No
Yes
No miscarriage
Yes, 1 miscarriage
Yes, 2 miscarriages
Yes, 3 or more miscarriages
Page 8
b. If YES, list the years of the 3
most recent miscarriages:
6488390862
Not
bothered
30. In the last 4 weeks, how much have you been bothered by
any of the following problems?
Bothered
a little
Bothered
a lot
a. Worrying about your health
b. Your weight or how you look
c. Little or no sexual desire or pleasure during sex
d. Difficulties with husband/wife, partner/lover, or boyfriend/girlfriend
e. The stress of taking care of children, parents, or other family members
f.
Stress at work outside of the home or at school
g. Financial problems or worries
h. Having no one to turn to when you have a problem
i.
Something bad that happened recently
j.
Thinking or dreaming about something terrible that happened to you in
the past - like your house being destroyed, a severe accident, being
hit or assaulted, or being forced into a sexual act
31. In the last year, have you been hit, slapped, kicked, or otherwise physically hurt
by someone, or has anyone forced you to have an unwanted sexual act?
No
Yes
32. Are you currently taking any medicine for anxiety, depression, or stress?
No
Yes
33. Over the past month, how many hours of sleep did you get in an average 24-hour period?
34. Please rate your sleep pattern for the past 2 weeks.
None
Mild
hours
Moderate
Severe
Very
severe
a. Difficulty falling asleep
b. Difficulty staying asleep
c. Problem waking up too early
d. Snoring
35. How satisfied/dissatisfied are you with your current sleep pattern?
Very satisfied
Generally satisfied
Somewhat dissatisfied
Very dissatisfied
36. To what extent do you consider your sleep pattern to interfere with your daily functioning (such as daytime fatigue,
ability to function at work/daily chores, concentration, memory, mood, etc.)?
Not at all interfering
A little
Somewhat
Much
Very much interfering
37. How noticeable to others do you think your sleeping pattern is in terms of impairing the quality of your life?
Not at all noticeable
Barely
Somewhat
Much
Very much noticeable
38. How worried/distressed are you about your current sleep pattern?
Not at all
A little
Somewhat
Much
Very much
39. During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?
Not at all during past month
Less than once a week
Page 9
Once or twice a week
Three or more times a week
0472390869
Not at
all
40. In the past month have you experienced...?
A little
bit
Moderately
Quite
a bit
Extremely
a. Repeated, disturbing memories of stressful
experiences from the past
b. Repeated, disturbing dreams of stressful
experiences from the past
c. Suddenly acting or feeling as if stressful
experiences were happening again
d. Feeling very upset when something happened that
reminds you of stressful experiences from the past
e. Trouble remembering important parts of stressful
experiences from the past
f.
Loss of interest in activities that you used to enjoy
g. Feeling distant or cut off from other people
h. Feeling emotionally numb, or being unable to have
loving feelings for those close to you
i.
Feeling as if your future will somehow be cut short
j.
Trouble falling asleep or staying asleep
k. Feeling irritable or having angry outbursts
l.
Difficulty concentrating
m. Feeling "super-alert" or watchful or on guard
n. Feeling jumpy or easily startled
o. Physical reactions when something reminds you of
stressful experiences from the past
p. Efforts to avoid thinking about your stressful
experiences from the past or avoid having feelings
about them
q. Efforts to avoid activities or situations because they
remind you of stressful experiences from the past
41. In general, would you say your health is: (Please select only one)
Excellent
Very good
Good
Fair
Poor
Fair
Poor
42. How would you describe the condition of your teeth and gums?
Excellent
Very good
Good
43. Choose the single best description of your USUAL daily activities.
You sit during the day and do not walk much.
You stand or walk a lot during the day, but do not carry or lift things often.
You lift or carry light loads, or climb stairs or hills often.
You do heavy work or carry heavy loads often.
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44. In a typical week, how much time do you spend participating in...
(Please mark both your typical "days per week" and "minutes
per day" doing these activities)
# of Days per week
you exercise
On those days,
how many
minutes per day
on average do
you exercise
None
a. STRENGTH TRAINING or work that strengthens your
muscles? (such as lifting/pushing/pulling weights)
AND
OR
b. VIGOROUS exercise or work that causes heavy
sweating or large increases in breathing or heart
rate? (such as running, active sports, marching, biking)
AND
OR
c. MODERATE or LIGHT exercise or work that causes
light sweating or slight increases in breathing or
heart rate? (such as walking, cleaning, slow jogging)
AND
Cannot physically do
None
Cannot physically do
45. On a typical day, how much time do you spend sitting and watching TV or
videos or using a computer?
OR
None
Cannot physically do
hours per day
46. The following questions are about activities you might do during a typical day. Does your health now limit you
in these activities? If so, how much?
No, not limited
Yes, limited
Yes, limited
at all
a little
a lot
a. Vigorous activities, such as running, lifting heavy objects, or
participating in strenuous sports?
b. Moderate activities, such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf?
c. Lifting or carrying groceries?
d. Climbing several flights of stairs?
e. Climbing one flight of stairs?
f. Bending, kneeling, or stooping?
g. Walking more than a mile?
h. Walking several blocks?
i. Walking one block?
j. Bathing or dressing yourself?
47. During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of your physical health?
No,
Yes,
Yes,
Yes,
none of
a little of
some of
most of
the time
the time
the time
the time
a. Cut down the amount of time you spent on work or
other activities
b. Accomplished less than you would like
c. Were limited in the kind of work or other activities
d. Had difficulty performing the work or other activities
(for example, it took extra effort)
Page 11
Yes,
all of
the time
4078390865
48. During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of any emotional problems (such as feeling depressed or anxious)?
No,
none of
the time
Yes,
a little of
the time
Yes,
some of
the time
Yes,
most of
the time
Yes,
all of
the time
a. Cut down the amount of time you spent on work or
other activities
b. Accomplished less than you would like
c. Didn't do work or other activities as carefully as usual
49. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your
normal social activities with family, friends, neighbors, or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
50. During the past 4 weeks, how much bodily pain have you had?
None
Very mild
Mild
Moderate
Severe
Very severe
51. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the
home and housework)?
Not at all
A little bit
Moderately
52. During the past 4 weeks, how much of the time:
(Select the single best answer for each question.)
None
of the
time
A little
of the
time
Quite a bit
Some
of the
time
A good
bit of
the time
Extremely
Most
of the
time
All
of the
time
a. Did you feel full of pep?
b. Have you been a very nervous person?
c. Have you felt so down in the dumps that
nothing could cheer you up?
d. Have you felt calm and peaceful?
e. Did you have a lot of energy?
f.
Have you felt downhearted and blue?
g. Did you feel worn out?
h. Have you been a happy person?
i.
Did you feel tired?
53. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with
your social activities (like visiting with friends, relatives)?
None of the time
A little of the time
Some of the time
Page 12
Most of the time
All of the time
0248390860
54. Please choose the answer that best describes how true or false each of the following statements is for you.
Definitely
true
Mostly
true
Not sure
Mostly
false
Definitely
false
a. I seem to get sick a little easier than other people
b. I am as healthy as anybody I know
c. I expect my health to get worse
d. My health is excellent
55. Compared to 3 years ago, how would you rate your physical health in general now?
Much better
Somewhat better
About the same
Somewhat worse
Much worse
56. Compared to 3 years ago, how would you rate your emotional health or well-being (such as feeling anxious,
depressed, or irritable) now?
Much better
Somewhat better
About the same
Somewhat worse
Much worse
Quite a bit
Extremely
57. In the last 4 weeks, how well have your family or friends supported you?
Not at all
A little bit
Moderately
58. Other than conventional medicine, what other health treatments have you used in the last 12 months?
a. Acupuncture
No
Yes
i.
High dose / megavitamin therapy
No
Yes
b. Biofeedback
No
Yes
j.
Homeopathy
No
Yes
c. Chiropractic care
No
Yes
k. Hypnosis
No
Yes
d. Energy healing
No
Yes
l.
No
Yes
e. Folk remedies
No
Yes
m. Relaxation
No
Yes
f.
No
Yes
n. Spiritual healing
No
Yes
g. Yoga
No
Yes
o. Meditation
No
Yes
h. Movement therapy
No
Yes
p. Breathing techniques
No
Yes
a. Body building supplements (such as amino acids, weight gain products, creatine, etc.)
No
Yes
b. Energy supplements (such as energy drinks, pills, or energy enhancing herbs)
No
Yes
c. Weight loss supplements
No
Yes
No
Yes
No
Yes
Herbal therapy
Massage
59. Have you taken any of the following supplements in the last 12 months?
60. a. Have you ever received the anthrax vaccine?
b. If YES, how many shots of the anthrax vaccine have you received?
61. Have you received the smallpox vaccine after 2001?
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4811390860
62. Indicate the degree to which the following statements are
true in your life...
Not
at
all
To a
To a
To a
To a
To a
very
very
small moderate great
small
great
degree degree degree degree degree
a. I prioritize what is important in life
b. I have an appreciation for the value of my own life
c. I am able to do good things with my life
d. I have an understanding of spiritual matters
e. I have a sense of closeness with others
f.
I have established a path for my life
g. I know that I can handle difficulties
h. I have religious faith
i.
I'm stronger than I thought I was
j.
I have learned a great deal about how wonderful people are
k. I have compassion for others
These next few questions are about drinking alcoholic beverages. Alcoholic beverages include beer, wine, and liquor
(such as whiskey, gin, etc.). For the purpose of this questionnaire:
One drink = one 12-ounce beer, one 4-ounce glass of wine, or one 1.5-ounce shot of liquor
63. In the past year, how often did you typically drink any type of alcoholic beverage?
Never
Rarely
Monthly
Weekly
Daily
If you marked NEVER, skip to question 72 on page 15
64. In the past year, on those days that you drank alcoholic beverages,
on average, how many drinks did you have?
drinks
65. In a typical week, how many drinks of each type of alcoholic beverage do you have?
beer(s)
liquor
wine
66. Last week, how many drinks of alcoholic beverages did you have?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
67. In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?
Sunday
days
68. In the past year, how often did you typically get drunk (intoxicated)?
Never
Monthly or less
2-4 times a month
Page 14
>4 times per month
1054390866
69. FOR MEN ONLY:
In the past year, how often did you typically have 5 or more drinks of alcoholic beverages within a 2-hour period?
Never
Monthly or less
2-4 times a month
>4 times per month
70. FOR WOMEN ONLY:
In the past year, how often did you typically have 4 or more drinks of alcoholic beverages within a 2-hour period?
Never
Monthly or less
2-4 times a month
>4 times per month
71. In the last 12 months, have any of the following happened to you more than once?
a. You drank alcohol even though a doctor suggested that you stop drinking because of a
problem with your health
No
Yes
b. You drank alcohol, were high from alcohol, or hung over while you were working, going to
school, or taking care of children or other responsibilities
No
Yes
c. You missed or were late for work, school, or other activities because you were drinking or
hung over
No
Yes
d. You had a problem getting along with people while you were drinking
No
Yes
e. You drove a car after having several drinks or after drinking too much
No
Yes
72. Have you ever felt any of the following?
a. Felt you needed to cut back on your drinking
No
Yes
b. Felt annoyed at anyone who suggested you cut back on your drinking
No
Yes
c. Felt you needed an "eye-opener" or early morning drink
No
Yes
d. Felt guilty about your drinking
No
Yes
a. Cigarettes
No
Yes
b. Cigars
No
Yes
c. Pipes
No
Yes
d. Smokeless tobacco (chew, dip, snuff)
No
Yes
No
Yes
73. In the past year, have you used any of the following tobacco products?
74. In your lifetime, have you smoked at least 100 cigarettes (5 packs)?
If you marked NO, skip to question 79 on page 16
75. At what age did you start smoking?
years old
76. How many years have or did you smoke an average of at least 3 cigarettes per day
(or one pack per week)?
years
Page 15
2530390866
77. When smoking, how many packs per day did you or do you smoke?
78. Have you ever tried to quit smoking?
Less than half a pack per day
Yes, and succeeded
Half to 1 pack per day
Yes, but not successfully
1 to 2 packs per day
No
More than 2 packs per day
If YES, list
most recent year
79. In the past 3 years, have any of the following life events happened to you?
a. You moved or changed residence more than once
No
Yes
2
0
b. You changed job, assignment, or career path involuntarily (for example,
you lost a job, or you had to take a job you did not like)
No
Yes
2
0
c. You or your partner had an unplanned pregnancy
No
Yes
2
0
d. You were divorced or separated
No
Yes
2
0
e. Suffered major financial problems (such as bankruptcy)
No
Yes
2
0
f.
No
Yes
2
0
g. Experienced sexual harassment
No
Yes
2
0
h. Suffered a violent assault
No
Yes
2
0
i.
Had a family member or loved one who became severely ill
No
Yes
2
0
j.
Had a family member or loved one who died
No
Yes
2
0
No
Yes
2
0
Suffered forced sexual relations or sexual assault
k. Suffered a disabling illness or injury
80. During the past 3 years, have you been PERSONALLY exposed
to any of the following? (do not include TV, video, movies,
computers, or theater)
No
Yes,
1 time
Yes,
more than
1 time
If YES, list
most recent year
of exposure
a. Witnessing a person's death due to war, disaster, or tragic event
2
0
b. Witnessing instances of physical abuse (torture, beating, rape)
2
0
c. Dead and/or decomposing bodies
2
0
d. Maimed soldiers or civilians
2
0
e. Prisoners of war or refugees
2
0
f.
2
0
g. Medical countermeasures for chemical or biological
warfare agent exposure
2
0
h. Alarms necessitating wearing of chemical or biological
warfare protective gear
2
0
Chemical or biological warfare agents
Page 16
2175390861
81. During the past 3 years, were you PERSONALLY
exposed to any of the following?
Don't
know
No
Yes
If YES, list
most recent year
of exposure
a. Occupational hazards requiring protective equipment, such
as respirators or hearing protection
2
0
b. Routine skin contact with paint and/or solvent and/or substances
2
0
c. Depleted uranium (DU)
2
0
d. Microwaves (excluding small microwave ovens)
2
0
e. Pesticides, including creams, sprays, or uniform treatments
2
0
f.
2
0
2
0
Pesticides applied in the environment or around living facilities
g. Any exposure, physical or psychological, during a military
deployment that had a significant impact on your health?
please specify
82. Were you ever injured from any of the following?
No
Yes, while
Yes,
Total # of
NOT deployed while deployed injury events
If YES, list date of
most recent injury
Month
Year
Were you
hospitalized or did
you lose more than
1 day of w ork
a. Training or sports injury
M
M
/
Y
Y
No
Yes
b. Blast / explosion / bullet
M
M
/
Y
Y
No
Yes
c. Motor vehicle accident/crash
M
M
/
Y
Y
No
Yes
If YES, to the crash question above, please answer the following for your most severe accident or crash.
c1. What type of vehicle was involved?
Motorcycle
c2. How many vehicles were involved?
Your vehicle only
c3. What was your role?
Driver
c4. What safety features did you use?
Seat belt
c5. What time and day of the week
did the crash occur?
Day of week:
Time of day:
c6. Which of the following factors (related to Speed
the DRIVER) were involved in the crash? Alcohol
Personal car/truck
Government vehicle
Multiple vehicles
Passenger
Helmet
Both
M
Tu
W
6 A.M. - Midnight
No
No
Neither
Th
F
Sat
Midnight - 6 A.M.
Sun
Yes Fatigue/drowsiness
Yes Distraction (i.e. cell phone use)
No
Yes
No
Yes
c7. Did any of the following contribute to the crash? Bad weather Poor road conditions Combat / enemy fire
Minor injury, no treatment sought
c8. Injury treatment:
Hospitalized
Number of days:
Clinic or office visit only
c9. Total number of work days lost as
c10. Total number of limited work
a result of the crash/accident:
days (do not include lost work days):
83. Did any injury you received in the past 3 years
involve the following?
No
Yes,
while deployed
Yes, while
NOT deployed
If YES, list date of
most recent injury
a. Being dazed, confused, or "seeing stars"
M
M
/
Y
Y
b. Not remembering the injury
M
M
/
Y
Y
c. Losing consciousness (knocked out)
M
M
/
Y
Y
If YES, approximately how long were you unconscious (knocked out) for?
Less than 1 minute
1-4 minutes
5-30 minutes
More than 30 minutes
Page 17
9503390863
Please answer question 84 ONLY if you are ENLISTED (Active Duty, Reserve, or National Guard).
All others please skip to question 85 on page 19
84. Review the list of military occupational categories below. Select the two categories that best match your military
job and fill in the two-digit codes for your primary job code and your secondary job code.
PRIMARY JOB CODE
SECONDARY JOB CODE
ENLISTED MILITARY OCCUPATIONAL CATEGORIES
INFANTRY, GUN CREWS & SEAMANSHIP SPECIALISTS
FUNCTIONAL SUPPORT & ADMINISTRATION
Infantry..................................................................................... 01
Armor or Amphibious............................................................... 02
Combat Engineering................................................................ 03
Artillery/Gunnery, Rockets or Missiles..................................... 04
Air Crew................................................................................... 05
Seamanship............................................................................ 06
Installation Security................................................................. 07
Personnel............................................................................ 50
Administration......................................................................51
Clerical/Personnel............................................................... 52
Data Processing.................................................................. 53
Accounting, Finance or Disbursing...................................... 54
Other Functional Support.................................................... 55
Religious, Morale or Welfare............................................... 56
Information or Education..................................................... 57
ELECTRONIC EQUIPMENT REPAIRERS
ELECTRICAL/MECHANICAL EQUIPMENT REPAIRERS
Radio/Radar.............................................................................10
Fire Control Electric Systems, Non-Missile.............................. 11
Missile Guidance, Control or Check-out.................................. 12
Sonar Equipment..................................................................... 13
Nuclear Weapons Equipment.................................................. 14
ADP Computers....................................................................... 15
Teletype or Cryptographic Equipment..................................... 16
Other Electronic Equipment..................................................... 19
Aircraft or Aircraft Related................................................... 60
Automotive.......................................................................... 61
Wire Communications......................................................... 62
Missile Mechanical or Electrical...........................................63
Armament or Munitions....................................................... 64
Shipboard Propulsion.......................................................... 65
Power Generating Equipment............................................. 66
Precision Equipment............................................................67
Other Mechanical or Electrical Equipment.......................... 69
COMMUNICATIONS & INTELLIGENCE SPECIALISTS
Radio or Radio Code............................................................... 20
Sonar....................................................................................... 21
Radar or Air Traffic Control..................................................... 22
Signal Intel/Electronic Warfare................................................ 23
Intelligence...............................................................................24
Combat Operations Control..................................................... 25
Communications Center Operations........................................ 26
CRAFTWORKERS
Metalworking....................................................................... 70
Construction........................................................................ 71
Utilities................................................................................. 72
Lithography..........................................................................74
Industrial Gas or Fuel Production........................................ 75
Fabric, Leather or Rubber................................................... 76
Other Craftworker................................................................ 79
HEALTH CARE SPECIALISTS
Medical Care............................................................................ 30
Ancillary Medical Support........................................................ 31
Biomedical Sciences or Allied Health...................................... 32
Dental Care..............................................................................33
Medical Administration or Logistics..........................................34
SERVICE & SUPPLY HANDLERS
Food Service....................................................................... 80
Motor Transport................................................................... 81
Material Receipt, Storage or Issue...................................... 82
Law Enforcement................................................................ 83
Personnel Service............................................................... 84
Auxiliary Labor..................................................................... 85
Forward Area Equipment Support....................................... 86
Other Services..................................................................... 87
OTHER TECHNICAL AND ALLIED SPECIALISTS
Photography............................................................................. 40
Mapping, Surveying, Drafting or Illustrating............................. 41
Weather................................................................................... 42
Ordnance Disposal or Diving................................................... 43
Musician................................................................................... 45
Technical Specialist................................................................. 49
OTHER
Patients or Prisoners........................................................... 90
Officer Candidate or Student............................................... 91
Undesignated Occupations................................................. 92
Not Occupationally Qualified............................................... 95
Page 18
8774390862
Please answer question 85 ONLY if you are an OFFICER or WARRANT OFFICER (Active Duty, Reserve, or National
Guard). All others please skip to question 86 on page 20
85. Review the list of military occupational categories below. Select the two categories that best match your military job
and fill in the two-digit codes for your primary job code and your secondary job code.
PRIMARY JOB CODE
SECONDARY JOB CODE
OFFICER or WARRANT OFFICER MILITARY OCCUPATIONAL CATEGORIES
TACTICAL OPERATIONS OFFICERS
GENERAL OFFICERS & EXECUTIVES
Fixed-Wing Fighter or Bomber Pilot................................... 2A
Helicopter Pilot....................................................................2C
Aircraft Crew.......................................................................2D
Ground or Naval Arms........................................................2E
Missiles.............................................................................. 2F
Operations Staff................................................................. 2G
Civilian Pilot........................................................................2H
General or Flag.........................................................................1A
Executive...................................................................................1B
INTELLIGENCE OFFICERS
Intelligence, General......................................................... 3A
Communications Intelligence............................................ 3B
Counter-intelligence........................................................... 3C
ENGINEERING & MAINTENANCE OFFICERS
Construction or Utilities...................................................... 4A
Electrical or Electronic........................................................4B
Communications or Radar................................................. 4C
Aviation Maintenance or Allied........................................... 4D
Ordnance........................................................................... 4E
Missile Maintenance...........................................................4F
Ship Construction or Maintenance..................................... 4G
Ship Machinery...................................................................4H
Safety................................................................................. 4J
Chemical............................................................................ 4K
Automotive or Allied........................................................... 4L
Surveying or Mapping....................................................... 4M
Other.................................................................................. 4N
SCIENTISTS & PROFESSIONALS
Physical Scientist............................................................... 5A
Meteorologist......................................................................5B
Biological Scientist............................................................. 5C
Social Scientist...................................................................5D
Psychologist....................................................................... 5E
Legal.................................................................................. 5F
Chaplain............................................................................. 5G
Social Worker.................................................................... 5H
Mathematician or Statistician............................................. 5J
Educator or Instructor.........................................................5K
Research & Development Coordinator...............................5L
Community Activities Officer.............................................. 5M
Scientist or Professional.....................................................5N
HEALTH CARE OFFICERS
Physician..................................................................................6A
Dentist.......................................................................................6C
Nurse....................................................................................... 6E
Veterinarian...............................................................................6G
Biomedical Sciences or Allied Health........................................6H
Health Service Administration..................................................6I
ADMINISTRATORS
Administrator, General............................................................. 7A
Training Administrator..............................................................7B
Manpower or Personnel............................................................7C
Comptroller or Fiscal................................................................7D
Data Processing.......................................................................7E
Pictorial.................................................................................... 7F
Information............................................................................... 7G
Police....................................................................................... 7H
Inspection.................................................................................7L
Morale & Welfare..................................................................... 7N
SUPPLY, PROCUREMENT & ALLIED OFFICERS
Logistics, General.................................................................... 8A
Supply...................................................................................... 8B
Transportation..........................................................................8C
Procurement or Production...................................................... 8D
Food Service............................................................................8E
Exchange or Commissary........................................................8F
Other........................................................................................ 8G
OTHER
Patient......................................................................................9A
Student.....................................................................................9B
Other........................................................................................ 9E
Page 19
0668390866
Please answer question 86 ONLY if you have a CIVILIAN job.
All others please skip to question 87 on page 22
86. Review the list of civilian occupational categories on this page and the next page. Select the two categories that best
match your civilian job and fill in the three-digit codes for your primary and your secondary job codes.
PRIMARY JOB CODE
SECONDARY JOB CODE
CIVILIAN OCCUPATIONAL CATEGORIES
More categories listed on page 21
ARCHITECTURE & ENGINEERING
EDUCATION, TRAINING & LIBRARY
Architect, Surveyor or Cartographer ...............................171
Engineer.......................................................................... 172
Drafter, Engineering or Mapping Technician................... 173
Postsecondary Teacher................................................. 251
Primary, Secondary or Special Education
School Teacher............................................................. 252
Other Teacher or Instructor............................................253
Librarian, Curator or Archivist........................................ 254
Other Education, Training or Library Occupation...........259
ARTS, DESIGN, MEDIA, ENTERTAINMENT & SPORTS
Art or Design................................................................... 271
Entertainer, Performer, Sports or Related Worker.......... 272
Media Communication Worker........................................273
Media Communication Equipment Worker......................274
FARMING, FISHING & FORESTRY WORKERS
Supervisor, Farming, Fishing or Forestry Worker..........451
Agricultural Worker........................................................ 452
Fishing or Hunting Worker............................................. 453
Forest, Conservation or Logging Worker.......................454
Other Farming, Fishing or Forestry................................459
BUILDING & GROUNDS CLEANING & MAINTENANCE
Supervisor, Building & Grounds, Cleaning &
Maintenance Worker....................................................... 371
Building Cleaning or Pest Control................................... 372
Ground Maintenance.......................................................373
FOOD PREPARATION & SERVING RELATED
Supervisor, Food Preparation or Serving.......................3511
Cook or Food Preparation Worker.................................352
Food and Beverage Worker...........................................353
Other Food Preparation or Serving Related Worker......359
BUSINESS & FINANCIAL OPERATIONS
Business Operations Specialist.......................................131
Financial Specialist..........................................................132
HEALTH CARE
COMMUNITY & SOCIAL SERVICES
Counselor, Social Worker or Other Community
or Social Service Specialist............................................. 211
Religious Worker.............................................................212
Physician........................................................................295
Nursing, Psychiatric or Home Health Aid....................... 311
Occupational or Physical Therapist Assistant or Aid......312
Other Health Care Occupation.......................................319
COMPUTER & MATHEMATICAL
INSTALLATION, REPAIR & MAINTENANCE
Computer Specialist ........................................................151
Mathematical Specialist...................................................152
Mathematical Technician.................................................153
Supervisor of Installation, Maintenance
or Repair Worker........................................................... 491
Electrical or Electric Equipment Mechanic,
Installer or Repairer....................................................... 492
Vehicle or Mobile Equipment Mechanic,
Installer or Repairer....................................................... 493
Other Installation, Maintenance or Repair......................499
CONSTRUCTION & EXTRACTION
Supervisor, Construction or Extraction Worker............... 471
Construction Trades Worker........................................... 472
Helper, Construction Trades........................................... 473
Other Construction or Related Worker............................474
Extraction Worker............................................................475
More categories listed on page 21...
Page 20
6749390862
Question 86 continued, Civilian occupational categories...
CIVILIAN OCCUPATIONAL CATEGORIES
LEGAL
PRODUCTION
Lawyer, Judge or Related Worker................................. 231
Legal Support Worker....................................................232
Life Scientist...................................................................191
Physical Scientist........................................................... 192
Social Scientist or Related Worker................................ 193
Life, Physical or Social Sciences Technician................. 194
Supervisor, Production Worker.....................................511
Assembler, Fabricator...................................................512
Food Processing Worker..............................................513
Metal or Plastic Worker.................................................514
Printing Worker.............................................................515
Textile, Apparel or Furnishing Worker.......................... 516
Woodworker..................................................................517
Plant or Systems Operator............................................518
Other Production Occupation....................................... 519
MANAGEMENT
PROTECTIVE SERVICES
Top Executive................................................................ 111
Advertising, Marketing, Promotions, PR or
Sales Manager...............................................................112
Operations Specialties Manager....................................113
Other Management Occupation.....................................119
First Line Supervisor/Manager, Protective Services.....331
Firefighting or Prevention Worker.................................332
Law Enforcement Worker.............................................333
Other Protective Service Worker..................................339
LIFE, PHYSICAL & SOCIAL SCIENCES
SALES-RELATED
OFFICE & ADMINISTRATIVE SUPPORT
Supervisor, Sales..........................................................411
Retail Sales Worker......................................................412
Sales Representative, Services....................................413
Sales Representative, Wholesale or Manufacturing.....414
Counter or Rental Clerk or Parts Salesperson..............415
Other Sales or Related Worker.....................................419
Supervisor, Office or Administrative Support................. 431
Communications Equipment Operator...........................432
Financial Clerk............................................................... 433
Information or Record Clerk...........................................434
Material Recording, Scheduling, Dispatching
or Distributing Worker.................................................... 435
Secretary or Administrative Assistant............................ 436
Other Office or Administrative Support.......................... 439
TRANSPORTATION & MATERIAL MOVING
Supervisor, Transportation or Material Moving.............531
Motor Vehicle Operator.................................................533
Rail Transportation Worker...........................................534
Water Transportation....................................................535
Other Transportation.....................................................536
Material Moving Worker................................................537
PERSONAL CARE SERVICE
Supervisor, Personal Care or Service............................391
Animal Care or Service.................................................. 392
Entertainment Attendant or Related Worker..................393
Funeral Worker.............................................................. 3941
Personal Appearance.................................................... 395
Transportation, Tourism or Lodging Attendant.............. 396
Other Personal Care or Service Worker........................ 399
Page 21
4196390866
88. What is your annual household income?
87. Which of the following best describes your
employment status? Choose the single best answer.
Full-time (greater than or equal to 30 hours per week)
less than $25,000
$25,000-$49,999
Part-time (less than 30 hours per week)
$50,000-$74,999
Not employed, looking for work
$75,000-$99,999
Not employed, not looking for work
$100,000-$124,999
Not employed, retired
$125,000-$149,999
Not employed, disabled
$150,000 or more
Homemaker
Other
please specify
89. Please indicate your level of agreement
with these statements:
Strongly
Disagree
Disagree
Neither
Agree nor
Disagree
Strongly
Agree
Agree
a. I have little control over the things that happen to me
b. What happens to me in the future mostly depends on me
c. I can do just about anything I really set my mind to do
Negative
Neither
Somewhat Negative nor Somewhat
Negative
Positive
Positive
Positive
90. What is your overall feeling about your military service?
91. Are you currently serving in the US military?
Yes, Active Duty
Yes, Reserve or National Guard
No
If you marked YES, skip to question 96 on page 23
92. How much did each of the following reasons affect
your decision to leave the military?
Not at
all
a. Dissatisfaction with deployments and/or
frequent moves
b. Military service created hardship for family
c. Dissatisfaction with promotion, pay, or other benefits
d. Dissatisfaction with job or leadership/supervision
e. Desire to continue your education, start a new career,
or change in personal goals
f.
Disability or other medical reasons
g. Difficulty meeting weight standards and/or
fitness standards
h. Incompatibility with the military
i.
Legal problems or problems meeting a
military obligation
j.
Fulfilled term of service or was retirement eligible
Page 22
A little
bit
Moderately
Quite
a bit
Extremely
6540390861
No
93. a. Has the VA determined that you have one or more service connected disabilities?
percent disability
b. If YES, indicate the total percent of your VA service connected disabilities.
None
94. Have you ever received any medical care from VA facilities?
Yes
Some of my care
All of my care
95. Are you currently employed by a US Federal agency or the US Federal government?
No
Yes
96. In the last 3 years, have you received imminent danger pay, hardship duty pay, or combat
zone tax exclusion benefits for deployment?
No
Yes
If you marked NO, skip to question 101 on page 24
97. Use the country and sea codes (01-27) assigned to the locations below to indicate the region(s) where you received
imminent danger pay, hardship duty pay, or combat zone tax exclusion benefits. Please list the most recent first.
Country Codes
01 Afghanistan
02 Bahrain
03 Bosnia or Herzegovina
04 Croatia
05 Iraq
06 Kuwait
07 Kyrgyzstan
08 Macedonia
09 Montenegro
10 Oman
11
Pakistan
Sea Codes
12
Philippines
21 Adriatic Sea
13
Qatar
22 Arabian Sea
14
Saudi Arabia
23 Gulf of Aden
15
Serbia (includes Kosovo)
24 Gulf of Oman
16
Tajikistan
25 Persian Gulf
17
Turkey
26 Red Sea
18
United Arab Emirates
27 Other sea area
19
Uzbekistan
20
Other country
please specify
please specify
Location
Date Arrived
Month
/
Date Departed
Year
Month
/
Year
a.
/
2
0
TO
/
2
0
b.
/
2
0
TO
/
2
0
c.
/
2
0
TO
/
2
0
d.
/
2
0
TO
/
2
0
e.
/
2
0
TO
/
2
0
f.
/
2
0
TO
/
2
0
98. In the last 3 years, have you been to more regions where you received imminent danger pay,
hardship duty pay, or combat zone tax exclusion benefits than fit into the space allowed above?
Page 23
No
Yes
5304390868
99. In the last 3 years, how often have you experienced the following during deployment?
Never
1 time
More than
1 time
List most
recent year
of exposure
a. Feeling that you were in great danger of being killed
2
0
b. Being attacked or ambushed
2
0
c. Receiving small arms fire
2
0
d. Clearing / searching homes or buildings
2
0
e. Having an improvised explosive device (IED)
or booby trap explode near you
2
0
f.
2
0
g. Seeing dead bodies or human remains
2
0
h. Handling or uncovering human remains
2
0
i.
Knowing someone seriously injured or killed
2
0
j.
Seeing Americans who were seriously injured
or killed
2
0
k. Having a member of your unit be seriously
injured or killed
2
0
l.
2
0
m. Being directly responsible for the death of a
non-combatant
2
0
n. Being exposed to smoke from burning trash and/or feces
2
0
Being wounded or injured
Being directly responsible for the death of an
enemy combatant
100. When you were returning from deployment, did you first go to a separate location other than your
home station and complete a structured decompression program?
No
Yes
If YES, please specify location:
101. Do you have any concerns about your health that are not covered in this questionnaire that you would like to share?
(Continue on a separate sheet if necessary.)
Thank you for completing this important questionnaire!
Your responses will help service members and veterans.
More information on the Millennium Cohort Study can be found at
http://www.MillenniumCohort.org
Page 24
| File Type | application/pdf |
| File Title | MilCo 2010 Follow-up (39086 - A |
| Author | Kari.Welch |
| File Modified | 2010-03-19 |
| File Created | 2010-03-19 |