Veteran's Community Reintegration Focus Groups

OMB No. 0704-TBD
OMB approval expires:
For Official Use Only:

TAP/Transition GPS Focus Group Intake Form
The information collected on this form will be used to compare the focus group sample of servicemembers to the entire population of servicemembers. Completing this form is voluntary. If there
are any questions you do not wish to answer, you may leave them blank. This form should take no
more than 10 minutes to complete

1. What was your age upon separation?
2. What is your gender?
 Female

 Male

3. Do you consider yourself to be Hispanic or Latino?
 Yes

 No

4. What is your race? Please check one or more.






White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander (e.g., Samoan, Guamanian, or Chamorro)

5. What was the highest degree or level of schooling that you had completed at the
time of separation? Mark the one answer that describes the highest grade or degree that
you had completed upon separation.









12 years or less of school (no diploma)
High school graduate–traditional diploma
High school graduate–alternative diploma (GED, home school, etc.)
Some college credit, but less than 1 year
1 or more years of college, no degree
Associate’s degree (e.g., AA, AS)
Bachelor’s degree (e.g., BA, AB, BS)
Master’s, doctoral, or professional degree (e.g., MA, MS, Med, MEng, MBA, MSW,
PhD, MD, JD, DVM, EdD)

1

6. What was your marital status at the time of separation?
 Married
 Separated

 Divorced
 Widowed

 Never Married

7. Did you have children or other legal dependents (excluding your spouse) at the
time of separation?
 Yes

 No

8. With which service are/were you affiliated?
 Army

 Navy

 Marine Corps

 Air Force

9. What was your pay grade upon separation?
 E1-E3
 E4-E6
 E7-E9

 W1-W5

 O1-O3
 O4-O6

10. How many months has it been since you were on active duty?
11. How many months were you deployed away from your home station during your
time on active duty?
12. How many of the months that you were deployed involved deployment within a
combat zone?
13. If you have transitioned off active duty, were you serving in the regular or reserve
component prior to separation?
 Regular

 Reserve

 Not applicable

14. If you are currently in the transition process, are you transitioning from the
regular or reserve component?
 Regular

 Reserve

 Not applicable

AGENCY DISCLOSURE STATEMENT
The public reporting burden for this Focus Group Intake Form is estimated to average
ten (10) minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing
the burden, to the Department of Defense, Washington Headquarters Services,
Executive Services Directorate, Information Management Division, 4800 Mark Center
Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-TBD). Respondents
should be aware that notwithstanding any other provision of law, no person shall be
subject to any penalty for failing to comply with a collection of information if it does
not display a currently valid OMB control number.
2