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MARKING INSTRUCTIONS
• Use blue or black ink.
• Shade circles like this.
• Include additional comments in the open text field on the last page.
1. In general would you say your health is: (Please select only one)
Excellent
Very good
Good
Fair
Poor
2. 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
Yes, limited
No, not
a lot
a little
limited at all
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 .......................................................................
3. 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 ........................................................................
Yes, all
of the
time
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) .................................
4. 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 .............
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5. 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
6. During the past 4 weeks, how much bodily pain have you had?
None
Very mild
Mild
Moderate
Severe
Very severe
7. 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
8. During the past 4 weeks, how much of the time:
(Select the single best answer for each question)
A little
of the
time
None
of the
time
a. Did you feel full of pep? ...........................................
Some
of the
time
Most
of the
time
A good
bit of the
time
All
of the
time
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? .....................................................
9. 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
10. 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 .................................................................
11. 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
12. 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
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Somewhat worse
Much worse
5487411774
13. What is your current marital status? Choose the single best answer.
Single, never married
Now married
Separated
Divorced
Widowed
14. (If not married) Please choose one of the following to describe your current relationship status:
In a committed relationship
Dating casually
Not seeing anyone
15. (If currently married) Taking things all together, how would you describe your marriage?
Very unhappy 1
2
3
4
5
6
7 Very happy
16. Including yourself, how many people currently reside in your household? (please do not include anyone that does
not live and sleep in your household the majority of the time, such as visiting relatives)
adults (18 and older)
children (17 and younger, please include any biological, adopted, or foster children)
17. What is the highest level of education that you have completed? Choose the single best answer.
Less than high school completion
Associate's degree
High school degree, GED, or equivalent
Bachelor's degree
Some college, no degree
Master's, doctorate, or professional degree
18. Since 2001, have you taken any educational courses?
Skip to question 19
No
Yes, at a military institution
Yes, at an academic institution (non-military)
Yes, at a trade or technical school
a. Did you complete a degree/certificate as a result of these courses?
No, didn't complete all the necessary coursework for a degree/certification
No, coursework still in progress
Yes
Year degree or certification completed ....................................
19. 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)
Not employed, retired
Part-time (less than 30 hours per week)
Not employed, disabled
Not employed, looking for work
Homemaker
Not employed, not looking for work
Other
(please specify)
20. How tall are you? For example, a person who is 5'8" should write 5 feet 8 inches..............
feet
inches
21. What is your current weight? ................................................................................................
pounds
22. How much did you weigh a year ago? ..................................................................................
pounds
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3498411774
If Yes, in what
year were you
first diagnosed?
23. In the last 3 years, has your doctor or other health professional
told you that you have any of the following conditions?
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
f.
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.
Bladder infection .................................................
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.
Hepatitis C ..........................................................
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. Degenerative joint disease .................................
No
Yes
Hospitalized
x. Lupus ..................................................................
No
Yes
Hospitalized
y. Multiple Sclerosis ................................................
No
Yes
Hospitalized
Any other heart condition (please specify)
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5140411770
Question 23 continued from the previous page
If Yes, in what
year were you
first diagnosed?
23. In the last 3 years, has your doctor or other health professional
told you that you have any of the following conditions?
z.
Mark here if you
were hospitalized
for the condition in
the last 3 years.
Crohn's disease ................................................
No
Yes
Hospitalized
aa. Stomach, duodenal, or peptic ulcer ..................
No
Yes
Hospitalized
bb. Ulcerative colitis or proctitis ..............................
No
Yes
Hospitalized
cc. Acid reflux/ gastroesophageal reflux disease
requiring medication .........................................
No
Yes
Hospitalized
dd. Significant hearing loss ....................................
No
Yes
Hospitalized
ee. Significant vision loss even with glasses or
contact lenses ...................................................
No
Yes
Hospitalized
ff.
Memory loss or memory impairment ................
No
Yes
Hospitalized
gg. Tinnitus/ ringing in the ears ..............................
No
Yes
Hospitalized
hh. Migraine headaches .........................................
No
Yes
Hospitalized
ii. Stroke ...............................................................
No
Yes
Hospitalized
jj. Traumatic brain injury (Do not include injuries
that resulted in only a concussion) ...................
No
Yes
Hospitalized
kk. Neuropathy caused reduced sensation
in the hands or feet ...........................................
No
Yes
Hospitalized
ll.
Seizures ............................................................
No
Yes
Hospitalized
mm. Sleep apnea .....................................................
No
Yes
Hospitalized
nn. Anemia .............................................................
No
Yes
Hospitalized
oo. Thyroid condition other than cancer .................
No
Yes
Hospitalized
pp. Cancer (please specify)
No
Yes
Hospitalized
qq. Chronic fatigue syndrome ................................
No
Yes
Hospitalized
rr.
Depression .......................................................
No
Yes
Hospitalized
ss. Schizophrenia or psychosis ..............................
No
Yes
Hospitalized
tt.
No
Yes
Hospitalized
uu. Posttraumatic stress disorder .........................
No
Yes
Hospitalized
vv. Infertility ............................................................
No
Yes
Hospitalized
ww. Other (please specify)
No
Yes
Hospitalized
Manic depressive disorder ...............................
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8674411775
24. 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.
Chest pain .............................
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.
Cough ......................................
No
Yes
p.
Unusual fatigue .....................
No
Yes
g. Fever .......................................
No
Yes
q.
Forgetfulness ........................
No
Yes
h. Sudden unexplained hair loss ..
No
Yes
r.
Confusion ..............................
No
Yes
i.
Earlobe pain ............................
No
Yes
s.
Other (please specify) ...........
No
Yes
j.
Sleepy all the time.....................
No
Yes
No
Yes
25. Over the past 3 years, have you had back pain, back aching, or back stiffness almost every day
that lasted for 3 months or more in a row? .....................................................................................
26. Over the past 3 years, approximately how many days were you hospitalized
because of illness or injury? (exclude hospitalization for pregnancy and childbirth) .......................
days
27. 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) ........
days
28. During 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. 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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0474411775
29. 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 ..........................
i.
If you answered "several days" or more to any item above, how difficult have these problems made it for you
to do your work, take care of things at home, or get along with other people?
Not at all difficult
Somewhat difficult
Very difficult
Extremely difficult
30. a. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic? ..............
No
Yes
No
Yes
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.
Did you have hot flashes or chills? .............................................................................................
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
k. Were you afraid you were dying? ...............................................................................................
No
Yes
If you marked NO, please skip to question 32
b. Has this ever happened to you before? ......................................................................................
c.
31. Think about your last bad anxiety attack.
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7711411776
32. Over the last 4 weeks, how often have you been bothered by any of the following problems?
Several
Not at all
days
a. Feeling nervous, anxious, on edge, or worrying a lot about different things
More than
half the days
If you marked NOT AT ALL, please skip to question 33
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 ..............................................................
33. 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
34. 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
15 or more times/week
35. 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
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? .............................................................
36. In the last 3 years, have you and a partner tried to get pregnant?
No
Yes
Not applicable
If you marked NO or NOT APPLICABLE, skip to question 38
37. If YES, in the last 3 years, have you and a partner been unsuccessful getting pregnant for a year or more
(not including time spent apart, such as deployment)?
No
Yes
38. In the last 3 years, if you and a partner got pregnant, did you have a miscarriage?
Does not apply (no pregnancy)
No miscarriage
Yes, 1 miscarriage
year
Yes, 2 miscarriages
years
Yes, 3 miscarriages
years
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1559411770
40. FOR WOMEN ONLY:
Yes
Does not
apply
Bothered
a little
Bothered
a lot
No
a. Are you currently pregnant? ..............................................................................................
b. Have you given birth within the last 3 years? ..................................................................
c.
In the last 3 years, have you been diagnosed with gestational diabetes by a
glucose tolerance test during pregnancy? ........................................................................
41. During the last 4 weeks, how much have you been bothered by any of the following problems?
Not
bothered
a. Worrying about your health ....................................................................................
b. Your weight or how you look ..................................................................................
c.
Little of 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 .......................................
42. Please indicate the degree to which the following statements describe your feelings and behavior.
Not at
all
0
1
2
3
4
5
6
Exactly
so
7
8
a. I often find myself getting angry at people or situations .....
b. When I get angry, I get really mad .....................................
c.
When I get angry, I stay angry ...........................................
d. When I get angry at someone, I want to hit or
clobber the person ..............................................................
e. My anger prevents me from getting along with people
as well as I'd like to .............................................................
43. How often in the past month did you get angry with someone and kick/smash something, get into a
fight or hit someone, or threaten someone with physical violence?
Never
1 time
2 times
3-4 times
5 or more times
44. Are you currently taking any medicine for anxiety, depression, or stress? ....................................
page 9
No
Yes
1447411776
45. In the last 12 months, did you use prescription-strength pain relievers (including any narcotics or medications such as
Codeine, OxyContin, Percocet)?
Never
Once a month
Few days per month
Few days per week
Daily
46. Over the past month, how many hours of sleep did you get in an average 24-hour period? .................
47. Please rate your sleep pattern for the past 2 weeks.
Mild
None
Moderate
Severe
hours
Very
severe
a. Difficulty falling asleep ................................................................
b. Difficulty staying asleep ..............................................................
c.
Problem waking up too early ......................................................
d. Snoring .......................................................................................
48. How satisfied/dissatisfied are you with your current sleep pattern?
Very satisfied
Generally satisfied
Somewhat dissatisfied
Very dissatisfied
49. 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
50. 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
51. How worried/distressed are you about your current sleep pattern?
Not at all
A little
Somewhat
Much
Very much
52. 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
Once or twice a week
Three or more times a week
53. Do you consider yourself to be:
Heterosexual or straight
Gay or lesbian
Bisexual
54. People are different in their sexual attraction to other people. Which best describes your feelings? Are you:
Only attracted to females
Mostly attracted to males
Mostly attracted to females
Only attracted to males
Equally attracted to females and males
Not sure
55. 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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On those days,
how many
minutes per day
on average do
you exercise
56. In a typical week, how much time do you spend participating in...
(Please mark both your typical "days per week"
# of days per
and "minutes per day" doing these activities)
week you exercise
a. STRENGTH TRAINING or work that strengthens
your muscles? (such as lifting/pushing/pulling weights)
b. VIGOROUS exercise or work that causes heavy
sweating or large increases in breathing or heart
rate? (such as running, active sports, marching,
biking)
c.
AND
days
OR
None
Cannot physically do
OR
None
Cannot physically do
minutes
days
AND
days
57. In the past month have you experienced…?
None
Cannot physically do
minutes
AND
MODERATE or LIGHT exercise or work that causes
light sweating or slight increases in breathing or heart
rate? (such as walking, cleaning, slow jogging)
OR
minutes
Not at all A little bit
a. Repeated, disturbing memories of stressful
experiences from the past ................................................
Moderately Quite a bit
Extremely
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 ...........
r.
Thinking about all items in question 57 a-q above, how difficult have these problems made it for you to
do your work, take care of things at home, or get along with other people?
Not at all difficult
s.
Somewhat difficult
Very difficult
Extremely difficult
Thinking about all items in question 57 a-q above, did these problems cause you to feel distress?
Not at all
A little bit
Moderately
Quite a bit
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Extremely
9560411770
58. On a typical day, how much time do you spend sitting and watching TV or
videos or using a computer? ...............................................................................................
hours per day
59. From the following list, indicate if you have used each health practice 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.
Massage ....................................
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
60. If you answered "Yes", to any item in question 59 above, has your level of satisfaction with
conventional medicine led you to seek alternative health practices? ................................................
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
d. Hormones for muscular strength, enhancement, or performance .............................................
No
Yes
Herbal therapy .........................
61. Have you taken any of the following supplements in the last 12 months?
62. In the last 4 weeks, how much have your family or friends supported you?
Not at all
A little bit
Moderately
Quite a bit
Extremely
63. Indicate the degree to which the following statements are
true in your life...
Not
at all
To a
To a
To a
very
To a
To a
very
great
small small moderate 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 .................................................
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4079411770
64. Please indicate your level of agreement
with these statements:
Neither
agree nor
Disagree disagree
Agree
Strongly
agree
a. Posttraumatic stress disorder (PTSD) or posttraumatic stress (PTS) symptoms ....................
No
Yes
b. Depression ....................................................................................................................................
No
Yes
c.
Anxiety ..........................................................................................................................................
No
Yes
d. Substance use ..............................................................................................................................
No
Yes
e. Anger ............................................................................................................................................
No
Yes
f.
Stress ............................................................................................................................................
No
Yes
g. Relationship/family issues ............................................................................................................
No
Yes
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 .............
65. In the last 12 months, did you seek care for any of the following concerns?
66. a. If you answered "Yes" to any of the items in question 65 above, how many times did you seek these services in
the last 12 months?
Once a year
A few times a year
Once a month
Several times a month
Weekly
b. Where did you receive care for these services? (check all that apply)
Military resource/provider
VA resource/provider
Civilian resource/provider
67. In the last 12 months, have you had a physical health concern for which you considered seeking medical care?
No
Yes
skip to question 68
a. (If YES) When you had these physical health concerns, how often did you seek care?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
b. If you did NOT seek care "All of the time", what were the reasons you did NOT seek care?
(check all that apply)
The problem wasn't bad enough to get help
I don’t trust health professionals
I preferred to manage the problem on my own
I don’t think health care treatment would help
Fear of negative effects on military career
Treatment might be uncomfortable or difficult
Concern that others would think negatively of me
Cannot afford treatment/no health insurance
68. a. Have you found it necessary to sleep in a shelter, on the streets, or in another non-residential
setting because of having no other place to stay? (Please only refer to instances during or
after military service time) .............................................................................................................
No
Yes
b. If YES, please indicate the dates of your most recent situation:
m
m
y
/
y
m
to
m
y
y
/
page 13
0760411773
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
69. 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 79 on page 15
70. In the past year, on those days that you drank alcoholic beverages, on average, how many drinks did you have?
drinks
71. In a typical week, how many drinks of each type of alcoholic beverage do you have? (If NONE, please enter 0)
beer(s)
wine
liquor
72. Last week, how many drinks of alcoholic beverages did you have? (If NONE, please enter 0)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
73. In the past year, on how many days did you have 5 or more drinks of any
alcoholic beverage? (If NONE, please enter 0) ................................................................................
days
74. 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
75. 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
76. 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
77. 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
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
c.
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4367411770
78. 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
80. In your lifetime, have you smoked at least 100 cigarettes (5 packs)? ............................................
No
Yes
79. In the past year, have you used any of the following tobacco products?
If you marked NO, skip to question 85
81. At what age did you start smoking? .................................................................................................
years old
82. How many years have or did you smoke an average of at least 3 cigarettes per day
(or one pack per week)? ...................................................................................................................
years
83. When smoking, how many packs per day did you or do you smoke?
Less than half a pack a day
Half to 1 pack per day
1 to 2 packs per day
More than 2 packs per day
84. Have you ever tried to quit smoking?
Yes, and succeeded
Yes, but not successfully
No
85. In the past 3 years, have any of the following life events happened to you?
No
Yes
If YES, list
most recent year
a. You moved or changed residence more than once ..................................
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) .....
c.
You or your partner had an unplanned pregnancy ....................................
d. You were divorced or separated ................................................................
e. Suffered major financial problems (such as bankruptcy) ..........................
f.
Suffered forced sexual relations or sexual assault ...................................
g. Experienced sexual harassment ...............................................................
h. Suffered a violent assault ..........................................................................
i.
Had a family member or loved one who became severely ill ....................
j.
Had a family member or loved one who died ............................................
k.
Suffered a disabling illness or injury ...........................................................
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9272411770
86. During the past 3 years, have you been PERSONALLY exposed to any of the following?
(Do not include TV, video, movies, computers, or theater)
Yes,
1 time
No
If YES, list
Yes,
more than most recent year
of exposure
1 time
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.
Chemical or biological warfare agents .............................................
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
It would be helpful for this study to know about the background experiences that may have happened to some people.
87 a. Before the age of 18, how often did a parent or other adult in your home ever hit, beat, kick, or physically hurt you
in any way?
Never
Once
More than once
Prefer not to answer
b. Before the age of 18, how often did a parent or other adult in your home ever touch your private parts when they
shouldn't have or make you touch their private parts? Or did a parent or other adult that took care of you force
you to have sex?
Never
c.
Once
More than once
Prefer not to answer
Before the age of 18, how often did you get scared or feel really bad because a parent or other adult in your home
called you names, said mean things to you or said that they didn't want you?
Never
Once
More than once
Prefer not to answer
d. When someone is neglected, it means that the grown-ups in their life didn't take care of them the way that they
should. They might not get enough food, take them to the doctor when they are sick, or make sure they have a
safe place to stay. At any time before the age of 18, were you neglected?
Never
Once
More than once
Prefer not to answer
88. During the past 3 years, were you PERSONALLY
exposed to any of the following?
No
Don't
know
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
Pesticides applied in the environment or around living facilities ...........
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0352411770
89. What is your current military status?
Active duty
skip to question 94
Reserve or National Guard
Separated
skip to question 92
Retired
skip to question 90
skip to question 90
m m
y
y
/
90. a. What was your date of separation/retirement from the military: ..........................
b. What was the reason for your separation/retirement from the military?
Planned separation
(end of service term/retirement)
Unplanned administrative separation
(e.g. military downsizing, failure to promote,
failure to meet service standards)
Medical separation
Other
(e.g. pregnancy, parenthood, educational
pursuits)
Disciplinary separation
91. How much did each of the following reasons affect
your decision to leave the military?
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
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 ..................................................................
e. Dissatisfaction with leadership/supervision ..................................
f.
Desire to continue your education, start a new career,
or change in personal goals ..........................................................
g. Disability or other medical reasons ...............................................
h. Difficulty meeting weight standards and/or fitness standards ......
i.
Incompatibility with the military ......................................................
j.
Legal problems or problems meeting a military obligation ...........
k. Fulfilled term of service or was retirement eligible ........................
92. Has the VA determined that you have one or more service connected disabilities? ......................
a. If YES, indicate the total percent of your VA service-connected disabilities. ...............
No
Yes
percent disability
93. In the last 3 years, have you received any medical care from Department of Veterans Affairs/Veterans Health
Administration facilities?
None
Very little
Some
Most
All of my care
94. What kind of health coverage or insurance do you currently have? (check all that apply)
No health coverage or insurance
Medicare
School health insurance plan
Medicaid
TRICARE or military health insurance plan
VA health care
Employer health insurance plan
(Department of Veterans Affairs/
Veterans Health Administration)
(self, spouse/partner, parent, or other family member)
page 17
7806411771
95. Have you deployed in the last 3 years? .....................................................
No
skip to question 100
Yes
96. If YES and on a SEA-based deployment, list the specific SEA-based area along with the dates you arrived and
departed from each location. Please list the most recent location first.
Date arrived
Date departed
Please list specific location here
m m
y y
m m
y y
/
/
/
/
a.
b.
c.
d.
/
/
/
/
97. If YES and on a LAND-based deployment, list the specific countries along with the dates you arrived and departed
from each location. Please list the most recent location first.
Date arrived
Date departed
Please list specific location here
m m
y y
m m
y y
/
/
/
/
a.
b.
c.
d.
/
/
/
/
98. 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.
Being wounded or injured .......................................................
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
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
l.
Being directly responsible for the death of an
enemy combatant ....................................................................
page 18
6581411770
99.
Within the last 3 years, were you injured while deployed from any of the following? If you experienced
more than 1 injury during deployment, please provide responses for the most severe injury.
a. Physical training or sports injury while deployed
No
skip to 99b
Yes
a1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
a2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
a3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
b. Blast/Explosion while deployed
No
Yes
skip to 99c
b1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
b2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
b3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
c.
Yes
Bullet/Shrapnel while deployed
No
Yes
skip to 99d
c1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
c2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
c3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
d. Motor vehicle accident/crash while deployed
No
Yes
skip to 100
d1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
d2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
d3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
page 19
9289411778
100.
Within the last 3 years, were you injured while NOT deployed from any of the following? If you
experienced more than 1 injury while not deployed, please provide responses for the most severe injury.
a. Physical training or sports injury while NOT deployed
Yes
No
a1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
a2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
a3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
b. Blast/Explosion while NOT deployed
Yes
No
b1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
b2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
b3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
c.
Yes
Bullet/Shrapnel while NOT deployed
Yes
No
c1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
c2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
c3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
d. Motor vehicle accident/crash while NOT deployed
Yes
No
d1. Did this injury involve being dazed, confused, "seeing stars," or not remembering the injury?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
d2. Did this injury involve losing consciousness (such as getting knocked out)?
No
Yes, 0-30 minutes
Yes, more than 30 minutes
d3. Were you ever hospitalized or did this injury disrupt your personal and/or work activities
for more than 1 day?
No
Yes
page 20
1411411777
101.
Within the last 3 years, have you been in a motor vehicle accident / crash while NOT deployed?
No
Yes
If NO, skip to question 102
a. How many motor vehicle accident / crash events in the last 3 years?
1
2
3 or more events
b. List the dates of the 3 most recent motor vehicle accident(s) / crash(s), and indicate which one of these was
the most severe event.
m
c.
m
y
y
/
Most severe event
/
Most severe event
/
Most severe event
For the most SEVERE motor vehicle accident/crash:
c1. What type of vehicle were you in?
Motorcycle
Personal car/truck
Government vehicle
c2. How many vehicles were involved?
Your vehicle only
Multiple vehicles
c3. What was your role?
Driver
Passenger
c4. Which of the following factors (related to the DRIVER) were involved in the motor vehicle accident /
crash?
Speed ............................................................................................................................
No
Yes
Alcohol ...........................................................................................................................
No
Yes
Fatigue/drowsiness .......................................................................................................
No
Yes
Distraction (e.g. cell phone) ..........................................................................................
No
Yes
Strong emotions (e.g. road rage) ..................................................................................
No
Yes
d. What is the total number of work days lost as a result of the motor vehicle accident / crash:
days
e. What treatment did you seek for your injuries from this motor vehicle accident / crash?
No treatment sought
Clinic or office visit only
page 21
Hospitalized: number of days: ....
days
9738411777
102.
What is your annual household income?
less than $25,000
$100,000-$124,999
$25,000-$49,999
$125,000-$149,999
$50,000-$74,999
$150,000 or more
$75,000-$99,999
103.
What is your overall feeling about your military service?
Negative
Somewhat negative
Neither negative nor positive
Somewhat positive
Positive
The statements below are about your relationships with other military personnel.
104.
If you had deployed in the last 3 years, please indicate how much you agree or disagree for each item, based on
your most recent deployment. If you have not deployed in the last 3 years, please indicate how much you
agree or disagree for each item based on your most recent assignment.
Strongly
disagree
Neither
Somewhat agree nor Somewhat Strongly
disagree
agree
agree
disagree
a. I felt a sense of camaraderie between myself and
others in my unit ..........................................................
b. I was impressed by the quality of leadership in my unit
c.
I was supported by the military ....................................
We really appreciate your answers to the questions on the survey. Please continue on to the last few questions on the
next 5 pages about your military occupational categories and contact information.
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9092411770
105. If you are ENLISTED (Active Duty, Reserve, or National Guard), please 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. All others, skip to question 106 on page 24.
PRIMARY JOB CODE
SECONDARY JOB CODE
ENLISTED MILITARY OCCUPATIONAL CATEGORIES
FUNCTIONAL SUPPORT & ADMINISTRATION
INFANTRY, GUN CREWS & SEAMANSHIP SPECIALISTS
Infantry.....................................................................................
Armor or Amphibious...............................................................
Combat Engineering................................................................
Artillery/Gunnery, Rockets or Missiles.....................................
Air Crew...................................................................................
Seamanship............................................................................
Installation Security.................................................................
01
02
03
04
05
06
07
Personnel............................................................................
Administration......................................................................
Clerical/Personnel...............................................................
Data Processing..................................................................
Accounting, Finance or Disbursing......................................
Other Functional Support....................................................
Religious, Morale or Welfare...............................................
Information or Education.....................................................
10
11
12
13
14
15
16
19
ELECTRICAL/MECHANICAL EQUIPMENT REPAIRERS
ELECTRONIC EQUIPMENT REPAIRERS
Radio/Radar.............................................................................
Fire Control Electric Systems, Non-Missile..............................
Missile Guidance, Control or Check-out..................................
Sonar Equipment.....................................................................
Nuclear Weapons Equipment..................................................
ADP Computers.......................................................................
Teletype or Cryptographic Equipment.....................................
Other Electronic Equipment.....................................................
COMMUNICATIONS & INTELLIGENCE SPECIALISTS
Radio or Radio Code...............................................................
Sonar.......................................................................................
Radar or Air Traffic Control.....................................................
Signal Intel/Electronic Warfare................................................
Intelligence...............................................................................
Combat Operations Control.....................................................
Communications Center Operations........................................
20
21
22
23
24
25
26
HEALTH CARE SPECIALISTS
Medical Care............................................................................
Ancillary Medical Support........................................................
Biomedical Sciences or Allied Health......................................
Dental Care..............................................................................
Medical Administration or Logistics..........................................
30
31
32
33
34
OTHER TECHNICAL AND ALLIED SPECIALISTS
Photography.............................................................................
Mapping, Surveying, Drafting or Illustrating.............................
Weather...................................................................................
Ordnance Disposal or Diving...................................................
Musician...................................................................................
Technical Specialist.................................................................
40
41
42
43
45
49
Aircraft or Aircraft Related...................................................
Automotive..........................................................................
Wire Communications.........................................................
Missile Mechanical or Electrical...........................................
Armament or Munitions.......................................................
Shipboard Propulsion..........................................................
Power Generating Equipment.............................................
Precision Equipment............................................................
Other Mechanical or Electrical Equipment..........................
50
51
52
53
54
55
56
57
60
61
62
63
64
65
66
67
69
CRAFTWORKERS
Metalworking.......................................................................
Construction........................................................................
Utilities.................................................................................
Lithography..........................................................................
Industrial Gas or Fuel Production........................................
Fabric, Leather or Rubber...................................................
Other Craftworker................................................................
70
71
72
74
75
76
79
SERVICE & SUPPLY HANDLERS
Food Service.......................................................................
Motor Transport...................................................................
Material Receipt, Storage or Issue......................................
Law Enforcement................................................................
Personnel Service...............................................................
Auxiliary Labor.....................................................................
Forward Area Equipment Support.......................................
Other Services.....................................................................
80
81
82
83
84
85
86
87
OTHER
Patients or Prisoners...........................................................
Officer Candidate or Student...............................................
Undesignated Occupations.................................................
Not Occupationally Qualified...............................................
page 23
1302411776
90
91
92
95
106. If you are an OFFICER or WARRANT OFFICER (Active Duty, Reserve, or National Guard), please 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. All others, skip to question 107
on page 25.
PRIMARY JOB CODE
SECONDARY JOB CODE
OFFICER or WARRANT OFFICER MILITARY OCCUPATIONAL CATEGORIES
TACTICAL OPERATIONS OFFICERS
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
INTELLIGENCE OFFICERS
Intelligence, General....................................................... 3A
Communications Intelligence.......................................... 3B
Counter-intelligence........................................................ 3C
ENGINEERING & MAINTENANCE OFFICERS
Construction or Utilities................................................... 4A
Ordnance........................................................................ 4B
Communications or Radar.............................................. 4C
Aviation Maintenance or Allied....................................... 4D
Electrical or Electronic.................................................... 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
GENERAL OFFICERS & EXECUTIVES
General or Flag..................................................................... 1A
Executive................................................................................ 1B
HEALTH CARE OFFICERS
Physician..............................................................................
Dentist...................................................................................
Nurse....................................................................................
Veterinarian...........................................................................
Biomedical Sciences or Allied Health.....................................
Health Service Administration................................................
6A
6C
6E
6G
6H
6I
ADMINISTRATORS
Administrator, General...........................................................
Training Administrator............................................................
Manpower or Personnel.........................................................
Comptroller or Fiscal..............................................................
Data Processing.....................................................................
Pictorial...................................................................................
Information.............................................................................
Police......................................................................................
Inspection...............................................................................
Morale & Welfare...................................................................
7A
7B
7C
7D
7E
7F
7G
7H
7L
7N
SUPPLY, PROCUREMENT & ALLIED OFFICERS
Logistics, General...................................................................
Supply....................................................................................
Transportation.......................................................................
Procurement or Production....................................................
Food Service..........................................................................
Exchange or Commissary......................................................
Other......................................................................................
8A
8B
8C
8D
8E
8F
8G
OTHER
Patient................................................................................... 9A
Student.................................................................................. 9B
Other...................................................................................... 9E
page 24
4864411772
107. If you have a CIVILIAN job, please 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 code.
PRIMARY JOB CODE
SECONDARY JOB CODE
CIVILIAN OCCUPATIONAL CATEGORIES
More categories listed on page 26
EDUCATION, TRAINING & LIBRARY
Postsecondary Teacher.................................................
Primary, Secondary or Special Education
School Teacher.............................................................
Other Teacher or Instructor............................................
Librarian, Curator or Archivist........................................
Other Education, Training or Library Occupation...........
ARCHITECTURE & ENGINEERING
Architect, Surveyor or Cartographer ............................... 171
Engineer.......................................................................... 172
Drafter, Engineering or Mapping Technician................... 173
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
BUILDING & GROUNDS CLEANING & MAINTENANCE
Supervisor, Building & Grounds, Cleaning &
Maintenance Worker....................................................... 371
Building Cleaning or Pest Control................................... 372
Ground Maintenance....................................................... 373
BUSINESS & FINANCIAL OPERATIONS
Business Operations Specialist....................................... 131
Financial Specialist.......................................................... 132
COMMUNITY & SOCIAL SERVICES
Counselor, Social Worker or Other Community
or Social Service Specialist............................................. 211
Religious Worker............................................................. 212
COMPUTER & MATHEMATICAL
Computer Specialist ....................................................... 151
Mathematical Specialist................................................... 152
Mathematical Technician................................................. 153
CONSTRUCTION & EXTRACTION
Supervisor, Construction or Extraction Worker...............
Construction Trades Worker...........................................
Helper, Construction Trades...........................................
Other Construction or Related Worker............................
Extraction Worker............................................................
471
472
473
474
475
251
252
253
254
259
FARMING, FISHING & FORESTRY WORKERS
Supervisor, Farming, Fishing or Forestry Worker..........
Agricultural Worker........................................................
Fishing or Hunting Worker.............................................
Forest, Conservation or Logging Worker.......................
Other Farming, Fishing or Forestry................................
451
452
453
454
459
FOOD PREPARATION & SERVING RELATED
Supervisor, Food Preparation or Serving.......................
Cook or Food Preparation Worker.................................
Food and Beverage Worker...........................................
Other Food Preparation or Serving Related Worker......
3511
352
353
359
HEALTH CARE
Physician........................................................................
Nursing, Psychiatric or Home Health Aid.......................
Occupational or Physical Therapist Assistant or Aid......
Other Health Care Occupation.......................................
295
311
312
319
INSTALLATION, REPAIR & MAINTENANCE
Supervisor of Installation, Maintenance
or Repair Worker...........................................................
Electrical or Electric Equipment Mechanic,
Installer or Repairer.......................................................
Vehicle or Mobile Equipment Mechanic,
Installer or Repairer.......................................................
Other Installation, Maintenance or Repair.....................
491
492
493
499
More categories listed on page 26...
page 25
4195411779
Question 107 continued, Civilian occupational categories...
CIVILIAN OCCUPATIONAL CATEGORIES
LEGAL
Lawyer, Judge or Related Worker................................. 231
Legal Support Worker.................................................... 232
LIFE, PHYSICAL & SOCIAL SCIENCES
Life Scientist...................................................................
Physical Scientist...........................................................
Social Scientist or Related Worker................................
Life, Physical or Social Sciences Technician.................
MANAGEMENT
Top Executive................................................................
Advertising, Marketing, Promotions, PR or
Sales Manager...............................................................
Operations Specialties Manager....................................
Other Management Occupation.....................................
OFFICE & ADMINISTRATIVE SUPPORT
Supervisor, Office or Administrative Support.................
Communications Equipment Operator...........................
Financial Clerk...............................................................
Information or Record Clerk...........................................
Material Recording, Scheduling, Dispatching
or Distributing Worker....................................................
Secretary or Administrative Assistant............................
Other Office or Administrative Support..........................
PERSONAL CARE SERVICE
Supervisor, Personal Care or Service............................
Animal Care or Service..................................................
Entertainment Attendant or Related Worker..................
Funeral Worker..............................................................
Personal Appearance....................................................
Transportation, Tourism or Lodging Attendant..............
Other Personal Care or Service Worker........................
191
192
193
194
111
112
113
119
431
432
433
434
435
436
439
391
392
393
3941
395
396
399
page 26
PRODUCTION
Supervisor, Production Worker.....................................
Assembler, Fabricator...................................................
Food Processing Worker..............................................
Metal or Plastic Worker.................................................
Printing Worker.............................................................
Textile, Apparel or Furnishing Worker..........................
Woodworker..................................................................
Plant or Systems Operator............................................
Other Production Occupation.......................................
511
512
513
514
515
516
517
518
519
PROTECTIVE SERVICES
First Line Supervisor/Manager, Protective Services.....
Firefighting or Prevention Worker.................................
Law Enforcement Worker.............................................
Other Protective Service Worker..................................
331
332
333
339
SALES-RELATED
Supervisor, Sales..........................................................
Retail Sales Worker......................................................
Sales Representative, Services....................................
Sales Representative, Wholesale or Manufacturing.....
Counter or Rental Clerk or Parts Salesperson..............
Other Sales or Related Worker.....................................
411
412
413
414
415
419
TRANSPORTATION & MATERIAL MOVING
Supervisor, Transportation or Material Moving.............
Motor Vehicle Operator.................................................
Rail Transportation Worker...........................................
Water Transportation....................................................
Other Transportation.....................................................
Material Moving Worker................................................
531
533
534
535
536
537
9683411776
108.
We would like to verify your contact information. Although we obtain address information from DoD sources, we
would like to ensure we have the best information to reach you. What is your current mailing address?
Apt/Suite:
Address Line 1:
City or (FPO/APO):
State/Province/Region
(or AA/AE/AP):
Zip/Postal Code:
Country:
109.
Please provide your phone number(s): (Separate multiple phone numbers with a space)
110.
Please provide your email address(es): (Separate multiple email addresses with a space)
111.
What year were you born? ..............................................................................................................
112.
What are the last four digits of your Social Security Number? .......................................................
m m
d
/
d
y
y
y
/
113.
What is today's date? .............................................................................
114.
A great deal has been learned from this study and as a result we may be asked to consider other
research possibilities. If other related research studies become available, may we contact you
to let you know about them? ............................................................................................................
115.
y
No
Yes
Do you have any concerns 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!
page 27
4711411773
| File Type | application/pdf |
| Author | Jennifer.Walstrom |
| File Modified | 2014-03-27 |
| File Created | 2014-03-20 |