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Consent Form
•
What is the study about?
You are being asked to be a volunteer in a longitudinal research study called "The Millennium Cohort
Family Study" conducted by the US Department of Defense (DoD). The purpose of this study is to
assess the interrelated health effects of military service on service members, spouses and their
children. You were selected to be a part of this study because you have been named as a spouse by
your sponsor _________ (sponsor's name will be electronically generated by linking the sponsor's
last 4 SSN and inserted in the blank space), who is a participant of the Millennium Cohort Study. For
more information on the Millennium Cohort Study, please visit www.MillenniumCohort.org.
Participation is completely voluntary, however, it is very important that you participate in order to
evaluate the availability of resources and the level of support that is needed in the lives of military
service members and their families. Your continued participation is still encouraged even if this
person is no longer your sponsor, your sponsor is no longer in the service, or if you are separated or
no longer co-residing.
•
What will participation involve?
You are being asked to do the following:
Complete the survey. The only option for completing this survey is online. You are also being asked
to complete 7 follow-up surveys over 21 years, with one survey to complete every 3 years. The
survey will take about 45 minutes to complete each time you complete it. The surveys contain
questions on a broad range of health, medical, and behavioral issues concerning yourself, your
spouse, and your children (if you have any). Some of the questions are of a sensitive nature. We
will connect your survey data to other medical and personnel data maintained by the Department of
Defense. If you are a military member and you separate from service and utilize the Department of
Veterans Affairs for your medical services, we also link to those medical and personnel data. Your
child(ren)'s survey data will NOT be linked to any other data, or medical records.
You will be contacted semi-annually to verify your contact information. You are one of approximately
10,000 volunteers being asked to participate in this very important study.
Nominal incentives will be offered for your participation. Upon completion of the survey, you will
have a choice of a $10 gift card. Gift cards will be mailed to you within 6 weeks of survey
completion.
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•
•
What risks are involved in the study?
The primary risks to you are those associated with the inappropriate disclosure of data you provide.
However, this research group has collected similar information from numerous studies over many
years without any cases of inappropriate disclosure. There is also the risk of possible discomfort
from answering some sensitive questions, but you may skip any question(s) that make you
uncomfortable. If you feel that you might need medical care or counseling you should make contact
with the appropriate health care personnel.
How will your data be protected against any risks?
All information collected through the Internet survey is done by using Secure Sockets Layer (SSL)
data transmission lines. SSL encrypts, or scrambles, all survey data sent over the Internet.
Information will only be understandable when it reaches the investigator database.
When your data are entered into computer files for analysis, your answers will be identified only by a
special study identification number known to you and research team members. Your social security
number and any other personal identification information will be removed from your survey and data
file. Even if someone outside the research team broke into the data files, it would be impossible for
them to identify your data. To minimize the risk of anyone breaking into the data files, those files will
be maintained on DoD computers protected by all the measures required by DoD computer security
regulations. All members of the research team with access to data files will be trained in DoD
computer security procedures specifically designed to protect sensitive data. Reports of the study
findings will contain only group data, so that no individual study participant can be identified. Similar
procedures have been used to protect data in previous studies conducted within this research
center.
According to the DoD Policy "Interim Regulations to Improve Privacy Protections for DoD Medical
Records" dated October 31, 2000, the information you provide is for research purposes only and
may not be disclosed except for specifically authorized purposes or with the consent of the individual
about whom the information pertains. Uses and disclosures of this information shall comply with
provisions of the Privacy Act and implementing regulations.
Individuals from official government agencies may inspect research records to ensure the rights and
safety of all research participants are protected. All data will be maintained until all research
questions have been addressed.
•
What are the benefits of participating in the study?
While your participation in this study will not directly benefit you, your participation is a critical step in
developing programs and interventions to increase the well-being of service members and their
families.
•
Will you be provided medical care based on your responses?
No. This is a population-based study and data collected will not be used to make decisions about
treatment that any individual should receive. If you feel that you might need medical care or
counseling you should make contact with the appropriate health care personnel.
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•
Do you have to participate?
No, you do not! Your participation must be completely voluntary. If you decide to participate, you
can stop at any time you wish or skip any question you choose. If you choose not to participate or to
discontinue your participation, you will not lose any benefit to which you are otherwise entitled. You
may change your mind and revoke your permission to further collect or use your health information at
any time. If you revoke your permission, no new health information about you will be gathered after
that date. However, unless specified otherwise, information that has already been gathered may still
be used for analyses. Collected data will be maintained until all research questions are answered.
To end participation, contact the principal investigators at [email protected] or (888)
942-5222.
Your participation may also be ended by the investigators. While this is not anticipated, available
funding or other logistical considerations could conceivably result in the early termination of the
t d
•
Who can provide additional information if you need it?
Questions about the research (science) aspects of this study should be directed to the principal
investigators of the Millennium Cohort Family Study at [email protected] or (888)
942-5222. You may also refer to the web site at www.familycohort.org for more information.
Questions about the ethical aspects of this study, your rights as a volunteer, or any problem related
to the protection of research volunteers should be directed to Christopher G. Blood, JD, MA,
Chairperson, Institutional Review Board, Naval Health Research Center, at
[email protected] or (619) 553-8386.
•
Where can you find your records if you wish to review them?
The principal investigators will be responsible for storing the consent form and other research records
related to this study. The records will be stored at the DoD Center for Deployment Health Research,
Naval Health Research Center, 140 Sylvester Road, San Diego, CA 92106-3521. You can review
your electronically submitted survey until the study ends by contacting the principal investigator at
[email protected] or (888) 942-5222.
Voluntary Consent
I consent to participate in the study described above. My consent is completely voluntary. My
consent is indicated by my typing in my name and selecting the "Yes, I agree" box below. (There will be
two boxes on the online consent form stating "Yes, I agree or No, I do not agree".)
Volunteer's printed name (first, middle initial, last)
Yes, I agree
No, I do not agree
Date (mm/dd/yyyy)
PLEASE PRINT THIS COPY FOR YOUR PERSONAL RECORDS.
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MARKING INSTRUCTIONS
• Answer each question to the best of your ability.
• It will take approximately 45 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.FamilyCohort.org
or call our toll-free number at (888) 942-5222 to provide an update.
6. What are the last four digits of YOUR Social
Security number?
4. What is YOUR date of birth?
1
Month
Day
9
Year
5. What is YOUR gender?
Male
7. What are the last four digits of your *SPONSOR'S
Social Security number?
Female
*SPONSOR refers to the military service member who is a member of the Millennium Cohort
Study and has named you as his/her spouse.
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10. What is YOUR Race/Ethnicity?
Choose the single best answer.
8. What is the highest level of education that YOU
have completed?
Choose the single best answer.
Less than high school completion/diploma
White non-Hispanic
Black non-Hispanic
High school degree/GED/or equivalent
Asian/Pacific Islander
Some college, no degree
Hispanic
Associate's degree
Native American
Bachelor's degree
Other, please specify ____________________
Master's, doctorate, or professional degree
11. Are YOU currently employed by a US Federal
agency or the US Federal government?
9. Which of the following best describes YOUR
employment status?
Choose the single best answer.
No
Full-time work (greater than or equal to 30 hours per week)
Yes
12. What is your annual household income?
Part-time work (less than 30 hours per week)
Not employed, looking for work
less than $25,000
Not employed, not looking for work
$25,000-$49,999
Not employed, retired
$50,000-$74,999
Not employed, disabled
$75,000-$99,999
Homemaker
$100,000-$124,999
Other
$125,000-$149,999
please specify
$150,000 or more
13. What is your current marital status with your *SPONSOR? Choose the single best answer.
Now married
Separated
Divorced
Widowed
Single, never married
*SPONSOR refers to the military service member who is a member of the Millennium Cohort
Study and has named you as his/her spouse. Regardless of your currrent marital status with
this sponsor, the term "your sponsor" will be referred to as "your spouse" throughout the
rest of this survey.
14. Including your current relationship, how many times have YOU been married? For example, if you have been
married one time only, please mark 1 for your response.
# of times married
15. How many years have you been married to your SPOUSE?
Not married
less than 2 years
2-5 years
6-10 years
11-15 years
15 or more years
16. How long have you and your spouse been in a committed relationship?
Not in a committed relationship
less than 2 years
2-5 years
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6-10 years
11-15 years
15 or more years
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17. Including yourself, how many people currently reside in your household?
# of total people
18. How tall are you? For example, a person who is 5'8" tall would write 5 feet 08 inches.
19. What is your current weight?
pounds
20. How much did you weigh a year ago?
21. Have you and a partner ever tried to
get pregnant?
No
Yes
Not applicable
inches
feet
pounds
23. a. If you and a partner ever got
pregnant, did you have a
miscarriage?
If you marked No or Not applicable,
skip to question 23
22. 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
b. If YES, list the years of the 3
most recent miscarriages:
Does not apply (no pregnancy)
No miscarriage
Yes, 1 miscarriage
Yes, 2 miscarriages
Yes, 3 or more miscarriages
Questions 24-52 ask about YOUR general health:
If you are FEMALE, please continue to question 24.
If you are MALE, please skip to question 25 on page 7.
24. 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
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?
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No
Yes
Does
not apply
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25. Has your doctor or other health professional ever 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 25 continued on page 8...
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Question 25 continued...
If YES, in what
year were you
first diagnosed?
Has your doctor or other health professional ever told you that you have
any of the following conditions?
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
No
Yes
Hospitalized
No
Yes
Hospitalized
No
Yes
Hospitalized
mm. Cancer
please specify
rr. Posttraumatic stress disorder
ss. Infertility
tt. Other
please specify
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26. During the last 12 months, 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
27. Over the past 12 months, 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
28. Over the past 12 months, 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
29. During the last 4 weeks, how much have you been bothered
by any of the following problems?
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
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16-20 days
Not
bothered
21 days or more
Bothered
a little
Bothered
a lot
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30. 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.
31. a. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic?
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
If you marked NO, please skip to question 33 on page 11
32. 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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33. Over the last 4 weeks, how often have you been bothered by any of the following problems?
Not
at all
Several
days
More
than half
the days
a. Feeling nervous, anxious, on edge, or worrying a lot about different things
If you marked NOT AT ALL, skip to question 34 below
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
34 a.
. Do you often feel that you can't control what or how much you eat?
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
35. In the last 3 months, have you done any of the following in order to avoid gaining weight?
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36. In the last 4 weeks, how much have you been bothered by any of the following problems?
Not
bothered
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
37. 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
38. Are you currently taking any medicine for anxiety, depression, or stress?
No
Yes
39. In the past month have you experienced...?
Not at
all
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
Question 39 continued on page 13...
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Not at
all
Question 39 continued...
In the past month have you experienced...?
A little
bit
Quite
a bit
Moderately
Extremely
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
40. In general, would you say your health is: (Please select only one)
Excellent
Very good
Good
Fair
Poor
Fair
Poor
41. How would you describe the condition of your teeth and gums?
Excellent
Very good
Good
42. 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
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
OR
None
Cannot physically do
None
Cannot physically do
None
Cannot physically do
43. 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?
Yes, limited
No, not limited
Yes, limited
a lot
at all
a little
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?
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44 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,
Yes,
none of
a little of
some of
most of
all of
the time
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)
45. 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,
Yes,
Yes,
Yes,
Yes,
none of
a little of
some of
most of
all of
the time
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. Didn't do work or other activities as carefully as usual
46. 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
47.During the past 4 weeks, how much bodily pain have you had?
None
Very mild
Mild
Moderate
Severe
Very severe
48. 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
Quite a bit
Extremely
Quite a bit
Extremely
49. In the last 4 weeks, how well have your family or friends supported you?
Not at all
A little bit
Moderately
50. Please indicate your level of agreement
with these statements:
Strongly
Disagree
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
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Disagree
Neither
Agree nor
Disagree
Agree
Strongly
Agree
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51. 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
Some
of the
time
A good
bit of
the time
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?
52. 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
Most of the time
All of the time
53. 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
54.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
55. 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
56. If you were ever to consider seeking care for a mental health, emotional, or stress-related reason, would the following
concern you enough to prevent you from going for care?
Definitely
Probably
Definitely
Probably
yes
yes
no
no
a. The financial cost to you of such care
b. What others would think of you if you went for such care
c. Not knowing where to go or who to go to for such care
d. The amount of time or the inconvenience of getting such care
e. Difficulty in getting to where the care is (distance or transportation
problems)
Question 56 continued on page 16...
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Question 56 continued...
If you were ever to consider seeking care for a mental health, emotional, or stress-related reason would the
following concern you enough to prevent you from going for care?
Definitely
Probably
Probably
yes
yes
no
f. The possibility that your treatment provider might find that you
needed some treatment you would not want
Definitely
no
g. Feeling that going for treatment would likely not do you any good
h. Feeling embarrassed or bad about yourself for needing such care
i.
The possibility that going for such care would hurt your career
j.
The possibility that you wouldn't like or trust your treatment
provider
k. The possibility that your supervisor or boss at work would treat
you differently or not trust you
l.
The possibility that your friends would treat you differently or not
like or trust you anymore
m. Feeling that you would be seen as weak
n. Feeling that you would not be able to get time off from work to go
for treatment
o. Feeling that psychological problems tend to work themselves out
without help
p. Feeling that getting mental health treatment should be a last
resort
q. Feeling that it takes courage to get treatment for a mental health
problem
57. How often in the PAST MONTH did you....
Never
a. Get angry at someone and yell or shout at them
b. Get angry with someone and kick/smash
something, slam the door, punch the wall, etc.
c. Get into a fight with someone and hit the person
d. Threaten someone with physical violence
e. Cry persistently or uncontrollably
f.
Sulk or refuse to talk about an issue
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One
time
Two
times
Three or
four times
Five or
more times
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Questions 58-67 ask about YOUR SPOUSE'S current or most recent deployment:
58. Since 2001, has your spouse been deployed?
No
Yes
If your spouse has not deployed since 2001, please skip to question 68 on page 19
59.How much has your spouse shared his/her deployment experiences with you?
Choose the single best answer.
None
A little
Somewhat
A lot
60. To what degree were/are you bothered by the deployment experiences your spouse shared with you?
Choose the single best answer.
Not at all
A little bit
Moderately
Quite a bit
61. Considering your spouse's CURRENT or MOST RECENT
deployment, rate how much you agree
Strongly
with the following:
disagree
a. I became more independent
b. The deployment experience increased my respect
for unit leaders
c. The deployment experience improved my ability to
deal with stress
d. The deployment experience improved my
relationship with my spouse
e. Being able to talk to my spouse during deployment
was stressful
f.
My spouse and I were able to communicate
sufficiently during deployment
g. My spouse was pleased with how I managed the
household/finances
h. After returning from deployment, my spouse
should have a period of light duty (e.g. halfdays)
for readjustment before going on leave
i.
j.
After returning from deployment, there should
be a period of time for my spouse to unwind
before rejoining the family
I feel mentally ready to have my spouse deploy
again
k. I have matured as a result of the deployment
l.
I'm confident the leadership will take care of my
spouse's safety while on deployment
m. I worry about my spouse being injured or killed
while on deployment
n. I feel that my spouse is well trained to handle
the dangers of deployment
Page 17
Extremely
Disagree
N/A, no deployment experiences
have been shared
Neither
agree nor
disagree
Agree
Strongly
agree
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62. During the CURRENT or MOST RECENT deployment or active duty assignment, how much support did YOU feel
you received from the following?
Moderate
None
Does not
A lot
Only a little
amount
at all
apply
a. Your extended family
b. Your friends
c. Your co-workers
d. Your neighbors
e. Your clergyman or chaplain
f.
Support group of those in a situation similar to
yours
g. Family and community support services
h. Your mental health provider (e.g. psychiatrist or
psychologist)
i.
Your primary care provider (e.g. family practice
doctor or nurse practitioner)
j.
Other military resources
63. If your spouse has returned from his/her CURRENT or MOST RECENT deployment, when did he/she return?
Month
Year
If he/she has not returned home yet, please skip to question 68 on page 19
64. Following your spouse's CURRENT or MOST RECENT deployment, rate how much you agree with the following:
The process of reunion/reintegration with your spouse was stressful.
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
65. Following your spouse's MOST RECENT deployment, did YOU personally participate in any redeployment
transition programs such as Return and Reunion? (For instance, programs on how to prevent or manage the stress
No
Yes
related to your spouse returning from a deployment or active duty assignment.)
If yes, please skip to question 67 on page 19
66. Indicate which of the following are reasons why YOU did not participate in a redeployment transition
Was this a
program.
reason for you?
a. No such program was available to me
No
Yes
b. I was not able to take the time to participate in the program
No
Yes
c. I had no child care available
No
Yes
d. I was unable to get off work to attend the program
No
Yes
e. I had previously received this training and did not need it again
No
Yes
f.
I did not think such training would help me
No
Yes
g. I was not aware these programs were available
No
Yes
h. My spouse was not supportive of the program
No
Yes
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67. Please choose the best answer regarding your spouse's CURRENT or MOST RECENT return from deployment.
(If your spouse has not returned from deployment, please skip to question 68 below. )
Less than 2
3-5
6 or more
Not yet
months
months
months
adjusted
a. How long did it take for YOU to adjust to your spouse's return
from being away from home?
b. How long did it take for YOUR SPOUSE to adjust to
his/her return home?
c. How long did it take for your relationship to return to the way it
was before he/she left home?
d. How long did it take for YOUR CHILDREN to adjust to his/her
return home? (If no children currently reside in your home,
please skip this question)
Questions 68-75 ask about YOUR relationship with your spouse:
68. Please rate the following statements:
Strongly
disagree
Disagree
Neither
agree nor
disagree
Agree
Strongly
agree
a. I have a good marriage
b. My relationship with my spouse is very stable
c. My relationship with my spouse makes me happy
d. I really feel like a part of a team with my spouse
e. I know how to access the military services that I
need
f.
I am confident in my ability to handle unexpected
problems
g. When I need suggestions about how to deal with
a personal problem, I know there is someone I
can turn to
h. There is someone I know who will tell me honestly
how I am handling my problems
69. Please rate the following statements regarding YOUR SPOUSE'S job:
Strongly
disagree
a. The demands of my spouse's work interfere with our
home and family life
b. The amount of time my spouse's job takes up makes it
difficult for HIM/HER to fulfill family responsibilities
c. My spouse's job produces stress/strain that makes it
difficult for HIM/HER to fulfill family responsibilities
d. My spouse's job produces stress/strain that makes it
difficult for ME to fulfill family responsibilities
e. Frequent TDY/TAD (training duty) interfere with our
home and family life
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Disagree
Neither
agree nor
disagree
Agree
Strongly
agree
1462585708
70. How often have you observed these behaviors IN YOUR SPOUSE within the PAST MONTH (or the most recent month
your spouse was home)?
Never
Seldom Sometimes
Often
Very often
a. Sudden bad memories/flashbacks
b. Spaces out
c. Lack of interest in sex/intimacy
d. Difficulty sharing thoughts and feelings
e. Avoids former interests/activities
f.
Hyper-alert/startles easily
g. Anxious/nervous
h. Fearful
i.
Withdrawn/detached
j.
Irritable
k. Quick temper
l.
Secretive
m. Difficulty falling or staying asleep
n. Nightmares or bad dreams
o. Taking more risks with his/her safety
p. Lack of interest in parenting/children (if you do not
have children, please skip to question 71 below)
71. Within the PAST MONTH (or the most recent month your spouse was home) how DIFFICULT has it been for
YOUR SPOUSE to do the following:
Not at all Somewhat
Very
Extremely
a. Do his/her work
b. Take care of things at home
c. Get along with other people
d. Fulfill supporting role as spouse/parent
72. Overall, how would you rate the military's efforts to help your spouse, you, and your family deal with the stresses
of military life?
a. Help your spouse:
Excellent
Very Good
Good
Fair
Poor
b. Help you and your family:
Excellent
Very Good
Good
Fair
Poor
73. On average, during the PAST MONTH, or the most recent month your spouse was home, how many HOURS did
your spouse work PER WEEK (including weekends)? Please round to nearest whole number and do not use
dashes or decimals.
hours per week
74. On average, during the past YEAR, how many DAYS of LEAVE from work did your spouse take? Please round to
nearest whole number and do not use dashes or decimals.
days in the past year
75. How many TOTAL MONTHS was your spouse away from home in the PAST YEAR (including deployments,
training, temporary duty-TDY/TAD)? Please round to nearest whole number and do not use dashes or decimals.
months in past year
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76. Many situations experienced by military families can be stressful for them. For each of the following possible stressful
situations you and your family personally experienced in the past 12 months, please indicate how stressful you felt it
was for you and your family.
Never
Very
Moderately
Slightly
Not at all
experienced
stressful
stressful
stressful
stressful
a. A combat-related deployment or duty assignment for
your spouse
b. A non-combat-related deployment or duty assignment
requiring your spouse to be away from home
c. Uncertainty about future deployments or duty
assignments
d. Combat-related injury to your spouse
e. A non-combat injury to your spouse from carrying out
his/her military duties
f.
Caring for your ill, injured, or disabled spouse
g. Intensified training schedule for your spouse
h. Increased time spouse spent away from family, or
missed family celebrations, while performing military
duties
i. Family conflict over whether spouse should remain in
the military or Reserves
j.
Difficulty balancing demands of family life and your
spouse's military duties
k. A permanent change of station(PCS)
l.
For Reserve Families only (If not a Reserve Family,
please skip to Question 77): Unpredictability of
when reservists will be activated for duty
m. For Reserve Families only: Changes in your family's
financial situation due to your spouse's active duty
n. For Reserve Families only: Concern over your
spouse's employment when de-activated
o. For Reserve Families only: Concern over
continuity of access to healthcare for your family
77. Have you ever had any of the following life events happen to you?
a. 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)
If YES, list most recent year
No
Yes
b. You or your partner had an unplanned pregnancy
No
Yes
c. You were divorced or separated
No
Yes
d. Suffered major financial problems (such as bankruptcy)
No
Yes
e. Suffered forced sexual relations or sexual assault
No
Yes
f.
Experienced sexual harassment
No
Yes
g.
Suffered a violent assault
No
Yes
h.
Had a family member or loved one who became severely ill
No
Yes
i.
Had a family member or loved one who died
No
Yes
j.
Suffered a disabling illness or injury
No
Yes
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Questions 78- 81 are about you when you were growing up, before you were 17 years old. Please choose the ONE
answer that comes closest to the way you felt.
Never
Rarely
Sometimes
Very often
Often true
true
true
true
true
78. a. There was someone to take care of you and protect you
b. You felt loved
Often
Very
often
80. Did you live with someone who was depressed or mentally ill?
No
Yes
81. Did you live with someone who was a problem drinker or alcoholic?
No
Yes
Generally
agree
Strongly
agree
Never
Once /
Twice
Sometimes
79. a. How often did a parent or adult living in your home swear
at you, insult you, or put you down?
b. How often did a parent or other adult living in your home
push, grab, shove, slap, or throw something at YOU?
c. How often did a parent or other adult living in your
home push, grab, shove, slap, or throw something at
EACH OTHER?
d. How often did an adult ever touch you sexually or try to
make you touch them sexually?
82. Please rate the following statements in regards to
your family:
Strongly
disagree
a. Family members are satisfied with how they
communicate with each other
b. Family members are very good listeners
c. Family members express affection to each other
d. Family members are able to ask each other for what
they want
e. Family members can calmly discuss problems with
each other
f.
Family members discuss their ideas and beliefs with
each other
g. When family members ask questions of each other,
they get honest answers
h. Family members try to understand each other's
feelings
i.
When angry, family members seldom say negative
things about each other
j.
Family members express their true feelings to each
other
Page 22
Generally
disagree
Undecided
1310585700
Very
dissatisfied
83. How satisfied are you with:
Somewhat
dissatisfied
Generally
satisfied
Very
satisfied
Extremely
satisfied
a. The degree of closeness between family members
b. Your family's ability to cope with stress
c. Your family's ability to be flexible
d. Your family's ability to share positive experiences
e. The quality of communication between family
members
f.
Your family's ability to resolve conflicts
g. The amount of time you spend together as a family
h. The way problems are discussed
i.
The fairness of criticism in your family
j.
Family members concern for each other
84. In your opinion, does YOUR SPOUSE consume too much alcohol in a typical week when he/she is at
home?
No
Yes
85. Do you have children from your current relationship or prior relationship(s)?
Yes
No -If no, please skip to question 99 on page 28
86. How many children do you have from your current relationship or prior relationship(s)?
1
2
3
4
5
6
7
8
9
10 or more
9
10 or more
87. What is the number of children currently living in your household?
1
2
3
4
5
6
7
8
88. Please select the ages for each of your children currently living in your household. Mark only one age for each child.
Child's Age in Years
Less than or
equal to 1
2
3
4
5
6
7
8
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
Child 9
Child 10
Page 23
9
10
11
12
13
14
15
16
17
18
6177585706
89. Has your child(ren) ever received any of these services or been placed in any of the following:
No
a. Inpatient psychiatric unit or a hospital for mental health problems
b. Residential treatment center (a self-contained treatment facility where
the child lives and goes to school)
c. Detention center, training school, jail, or prison
d. Group home (a group residence in a community setting)
e. Treatment foster care (placement with foster parents who receive
special training and supervision to help children with problems)
f.
Probation officer or court counselor
g. Day treatment program (a day program that includes a focus on therapy
and may also provide education while the child is there)
h. Case management or care coordination (someone who helps the
child get the kinds of services he/she needs)
i.
In-home counseling (services, therapy, or treatment provided in the
child's home)
j.
Outpatient therapy (from psychologist, social worker, therapist, or other
counselor)
k. Outpatient treatment from a psychiatrist
l.
Primary care physician/pediatrician for symptoms related to trauma
or emotional/behavioral problems (excluding emergency room)
m. School counselor, school psychologist, or school social
worker (for behavioral or emotional problems)
n. Special class or special school (for all or part of the day)
o. Child Welfare or Department of Social Services (include any type
of contact)
p. Foster care (placement in kinship or non-relative foster care)
q. Therapeutic recreation services or mentor
r.
Hospital emergency room (for problems related to trauma or
emotional or behavioral problems)
s. Self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous)
Page 24
Yes
Unknown
1604585706
90. For each of your children 3 to 17 years of age living at home, mark whether you have observed the following behaviors
in the PAST MONTH. Mark all that apply
N/A - I do not have child(ren) 3 to 17 years of age
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
a. Restless, overactive, cannot stay still for long
b. Often complains of headaches, stomach-aches, or
sickness
c. Often loses temper
d. Generally well behaved, usually does what adults
request
e. Many worries or often seems worried
f.
Constantly fidgeting or squirming
g. Often fights with other children or bullies them
h. Often unhappy, depressed, or tearful
i.
Easily distracted, concentration wanders
j.
Nervous or clingy in new situations, easily loses
confidence
k. Often lies or cheats
l. Thinks things out before acting
m. Steals from home, school, or elsewhere
n. Many fears, easily scared
o. Good attention span, sees chores or homework
through to the end
91 Please indicate if you have noticed any of the following, or if any of the following have occurred involving your child(ren)
aged 3 to 17 years of age.
N/A - I do not have child(ren) 3 to 17 years of age
a. My child(ren) is/are very unhappy, sad, or depressed
No
Yes
b. My child(ren) has/have had problems with worrying, anxiety, or nervousness
No
Yes
c. My child(ren) has/have had problems controlling his/her temper or anger
No
Yes
d. My child(ren) has/have gotten into fights at school
No
Yes
e. My child(ren) has/have had problems with paying attention, concentration, or
sitting still
No
Yes
f.
No
Yes
g. My child(ren) has/have hurt or threatened to hurt him/herself
No
Yes
h. My child(ren) has/have made close friends
No
Yes
i.
My child(ren) is/are adjusting well
No
Yes
j.
My child(ren) has/have been recognized for his/her successes in school
No
Yes
k. The school has recommended my child(ren) receive psychological testing or
counseling
No
Yes
No
Yes
No
Yes
l.
My child(ren) is/are having academic problems
Our family doctor/pediatrician provided treatment for my child(ren)'s behavior,
learning, or emotional problems (e.g. counseling, medication, etc)
m. Our family doctor/pediatrician recommended my child(ren) see a specialist
for his/her behavioral, learning, or emotional problem
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92. Has a doctor or health professional ever told you that your child(ren) has any
of the following conditions?
No
a. Attention Deficit Disorder (ADD) or Attention Deficit
Hyperactive Disorder (ADHD)
b. Depression
c. Anxiety problems or other emotional problems
d. Eating disorder
e. Behavioral or conduct problems, such as oppositional
defiant disorder or conduct disorder
f.
Autism or Autism Spectrum Disorder (ASD)
g. Any developmental delay that affects (his/her) ability to
learn
h. Stuttering, stammering, or other speech problems
i.
Tourette Syndrome
j.
Asthma
k. Diabetes
l.
Cystic Fibrosis
m. Cerebral Palsy
n. Muscular Dystrophy
o. Epilepsy or other seizure disorder
p. Migraine or frequent headaches
q. Arthritis or other joint problems
r.
Non-food allergies
s. Food allergies
t.
Hearing problems
u. Vision problems that cannot be corrected with glasses
or contact lenses
v. A brain injury or concussion
w. Blood problems such as anemia or sickle cell disease
Page 26
Yes
If Yes,
Mild
Moderate
Severe
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93. Is one or more of your children CURRENTLY experiencing a behavioral, emotional, or learning problem?
No
Yes, Mild
Yes, Moderate
Yes, Severe
94. Are you CURRENTLY interested in your child(ren) receiving mental health services/counseling?
No
Yes
If no, please skip to question 97
95. Did your child(ren) ever receive mental health services/counseling from a:
Never
Once
Twice
Three or
more times
a. Mental health professional at a military facility
b. General medical doctor at a military facility
c. Military chaplain
d. Mental health professional at a civilian facility
e. General medical doctor at a civilian facility
f.
Civilian clergy
g. Counseling through Military OneSource
If you marked NEVER to all of the above, please continue to question 96 below
Otherwise, please skip to question 97 below
96. Indicate which of the following are reasons why your child(ren) did not receive mental health services/counseling?
Was this a reason
for you?
a. No such services were available for my child(ren)
No
Yes
b. I did not have the time for my child(ren) to participate
No
Yes
c. I was unable to get off work to take my child(ren) to the services
No
Yes
d. I did not think such services would help my child(ren)
No
Yes
e. I was not aware these services were available
No
Yes
f.
No
Yes
My spouse was not supportive of these services for my child(ren)
97. On a typical day, how much time does your child(ren) spend sitting and watching TV or videos or using a
computer? (Please round to the nearest number, do not use dashes or decimals.)
hours per day
98. Please indicate the degree to which your child(ren) was/were disturbed or upset by your spouse's most recent or
current deployment or active duty assignment
A lot
More than just a moderate amount
A moderate amount
Only a little
Not at all
N/A- no current/most recent deployment or active duty assignment
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4322585706
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
99. In your entire life, have you had at least 12 drinks of any type of alcoholic beverage
(including beer and wine)?
No
Yes
If you marked NO, skip to question 110 on page 29
100. 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 109 on page 29
101. In the past year, on those days that you drank alcoholic beverages, on average, how many
drinks did you have?
102. In a typical week, how many drinks of each type of
alcoholic beverage do you have?
beer(s)
drinks
wine
liquor
103. Last week, how many drinks of alcoholic beverages did you have?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
104. In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?
days
105. In the past year, how often did you typically get drunk (intoxicated)?
Never
Monthly or less
2-4 times a month
>4 times per month
FOR MEN ONLY:
106. 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
FOR WOMEN ONLY:
107. 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
Page 28
>4 times per month
2625585700
108. 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
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
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
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
109. Have you ever felt any of the following?
Questions 110-115 ask about YOUR use of tobacco products:
110. In the past year, have you used any of the following tobacco products?
a. Cigarettes
No
Yes
b. Cigars
No
Yes
c. Pipes
No
Yes
d. Smokeless tobacco (chew, dip, snuff)
No
Yes
No
Yes
111. In your lifetime, have you smoked at least 100 cigarettes (5 packs)?
If you marked NO, skip to question 116 below
112. At what age did you start smoking?
years old
113. How many years have or did you smoke an average of at least 3 cigarettes per day (or one
pack per week)?
years
114. When smoking, how many packs per day did you or do you smoke?
Less than half a pack per day
Half to 1 pack per day
1 to 2 packs per day
More than 2 packs per day
115. Have you ever tried to quit smoking?
Yes, and succeeded
Yes, but not successfully
116. Are you currently taking any medicine for anxiety, depression, or stress?
Page 29
No
No
Yes
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Questions 117-123 Ask about YOUR personal sleep quality:
117. Over the past month, how many hours of sleep did you get in an average 24-hour period?
118. Please rate your sleep pattern for the past 2 weeks.
Mild
None
hours
Moderate
Severe
Very
severe
a. Difficulty falling asleep
b. Difficulty staying asleep
c. Problem waking up too early
d. Snoring
119. How satisfied/dissatisfied are you with your current sleep pattern?
Very satisfied
Generally satisfied
Somewhat dissatisfied
Very dissatisfied
120. To what extent do you consider your sleep pattern to INTERFERE with your daily functioning (e.g. daytime fatigue,
ability to function at work/daily chores, concentration, memory, mood, etc.)?
Not at all interfering
A little
Somewhat
Much
Very much interfering
121. How noticeable to others do you think your sleeping pattern is in terms of impairing the quality of your life?
Not at all noticeable
A little
Somewhat
Much
122. How worried/distressed are you about your current sleep problem?
Not at all
A little
Somewhat
Very much noticeable
Much
Very much
123. During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?
Not during past month
Less than once a week
Once or twice a week
Three or more times a week
Questions 124-130 Ask about YOUR personal military experience:
124. Have YOU ever served in the US military?
Yes, Active Duty
Yes, Reserve or National Guard
Yes, both
If you marked NO, skip to question 131 on page 32
125. Are YOU currently serving in the US military?
Yes, Active Duty
Yes, Reserve or National Guard
126. Why did you join the military (Active Duty, Reserve, or National Guard)? Mark all that apply.
For education and new job skills
Family member was in the military
For travel and adventure
20-year career in the military
For a job to earn money
To serve my country
To leave problems at home
Other, please specify___________________
127. What is your overall feeling about your military service?
Negative
Somewhat negative
Neither negative or positive
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Positive
Somewhat positive
No
No
5081585709
128. Have you ever been PERSONALLY exposed to any of the following?
(do not include TV, video, movies, computers, or theater)
No
Yes,
1 time
Yes,
If YES, list
more than most recent year
1 time
of exposure
a. Witnessing a person's death due to war, disaster, or tragic event
b. Witnessing instances of physical abuse (torture, beating, rape)
c. Dead and/or decomposing bodies
d. Maimed soldiers or civilians
e. Prisoners of war or refugees
f.
Chemical or biological warfare agents
g. Medical countermeasures for chemical or biological
warfare agent exposure
h. Alarms necessitating wearing of chemical or biological
warfare protective gear
129. Since 2001, have you received imminent danger pay, hardship duty pay, or combat zone tax
exclusion benefits for deployment?
No
Yes
If you marked NO, please skip to question 131 on page 32
130. Since 2001, 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.
2
0
2
0
2
0
2
0
2
0
2
0
Being wounded or injured
Knowing someone seriously injured or killed
j.
Seeing Americans who were seriously injured
or killed
k. Having a member of your unit be seriously
injured or killed
l. Being directly responsible for the death of
enemy combatant
m. Being directly responsible for the death of a
non-combatant
n. Being exposed to smoke from burning trash and/or feces
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0112585709
131. 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.)
132. Is there anything you didn't understand or would change in this survey?
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 enclosed consent form, you are volunteering 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 disadvantages or 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 45 minutes. Comments on the burden or content of the instrument
should be sent to the Millennium Cohort Family 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.
This is the end of the survey.
Thank you for your participation.
Page 32
| File Type | application/pdf |
| File Title | Millennium Cohort Family Survey |
| Author | Kari.Welch |
| File Modified | 2010-03-19 |
| File Created | 2010-03-19 |