Prospective Studies of US Military Forces: The Millennium Cohort Study

2017_Millennium Cohort Follow Up_Survey_Sourced_2018_02_21 (1)

Prospective Studies of US Military Forces: The Millennium Cohort Study

OMB: 0703-0064

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0703-0064 can be found here:

2021-08-23 - Revision of a currently approved collection

Document [pdf]

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OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

Millennium Cohort Follow‐Up 2018 Survey

The text in red on the following survey document indicates the source of the survey question.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

Privacy Act Statement
You have rights under the Privacy Act.
The following statement describes how that ACT applies to this study:
The Privacy Act System of Records Notice (SORN) for this study is N6500-1. The SORN was published on the
Defense Privacy and Civil Liberties Division (DPCLD) website on November 14, 2014 and can be found by
visiting: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-Component-Article-View/Article/570396/
n06500-1/

Authority: Authority to request this information is granted under: 10 USC 136, Under Secretary of Defense for
Personnel and Readiness, 10 USC 1782, Surveys of Military Families, 10 USC 2358, Research and Development
Projects, Under Secretary of Defense Memorandum #: 99-028, 30 SEP 99 "Establishment of DoD Centers for
Deployment Health” and Executive Order 9396, Numbering System for Federal Accounts Relating to Individual
Persons.

Purpose: To create a probability-based database of service members and veterans who have, or have not,
deployed overseas so that various longitudinal health and research studies may be conducted over a 67-year
period. The database will be used: (a.) To systematically collect population-based demographic and health
data to evaluate the health of Armed Forces personnel throughout their careers and after leaving the service.
(b.) To evaluate the impact of operational deployments on various measures of health over time including
medically unexplained symptoms and chronic diseases to include cancer, heart disease and diabetes. (c.) To
serve as a foundation upon which other routinely captured medical and deployment data may be added to
answer future questions regarding the health risks of operational deployment, occupations, and general
service in the Armed Forces. (d.) To examine characteristics of service in the Armed Forces associated with
common clinician-diagnosed diseases and with scores on several standardized self-reported health
inventories for physical and psychological functional status. (e.) To provide a data repository and available
representative Armed Forces cohort that future investigators and policy makers might use to study important
aspects of service in the Armed Forces including disease outcomes among an Armed Forces cohort.
In addition to revealing changes in Service member and veteran’ health status over time, the Millennium
Cohort Study will serve as a data repository, providing a solid foundation upon which additional
epidemiological studies may be constructed.

Routine Uses: The information provided in this questionnaire will be maintained in data files at the
Deployment Health Research Department 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. In addition to those
disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information
contained therein may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C.
522a(b)(3).

To the Department of Veterans Affairs (DVA) for (1) considering individual claims for benefits for which that
DVA is responsible; and (2) for use in scientific, medical and other analysis regarding health outcomes
research associated with military service. To the Department of Health and Human Services, Centers for
Disease Control and Prevention for use in scientific, medical and other analysis regarding health outcome
research associated with military service.

NOTE: All disclosures to the DVA and HHS must have prior approval of the Naval Health Research Center
Institutional Review Board and a Memorandum of Understanding must be entered into to ensure the right
and obligations of the signatories are clear. Access to data 1) is provided on need-to-know basis only; 2) must
adhere to the rule of minimization in that only information necessary to accomplish the purpose for which the
disclosure is being made is releasable; and 3) must follow strict guidelines established in the data sharing
agreement. To the Social Security Administration (SSA) for considering individual claims for benefits for
which that SSA is responsible. The DoD 'Blanket Routine Uses' that appear at the beginning of the Navy's
compilation of systems of records notices apply to this system.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
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NOTE: This system of records contains individually identifiable health information. The DoD Health
Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and
Accountability Act of 1996, applies to most such health information. DoD 6025.18-R may place additional
procedural requirements on the uses and disclosures of such information beyond those found in the Privacy
Act of 1974 or mentioned in this system of records notice.
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.
Agency Disclosure Notice
The public reporting burden for this collection of information, OMB Control Number 0703-0064, is
estimated to average 45minutes 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 the burden estimate or burden reduction suggestions to
the Department of Defense, Washington Headquarters Services, at [email protected]. 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.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

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

SF36V
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?
No, not
Yes, limited Yes, limited
SF36V
at all
a little
a lot
a. Vigorous activities, such as running, lifting heavy objects, or
participating in strenuous sports
b. Moderate activities, such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf
c.

Lifting or carrying groceries

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

Bathing or dressing yourself

d. Climbing several flights of stairs

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,
Yes,
SF36V
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)

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,
Yes,
Yes,
Yes,
Yes,
SF36V
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

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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
SF36V

6. During the past 4 weeks, how much bodily pain have you had?
None
Very mild
Mild
Moderate

SF36V
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)?
SF36V
Not at all
A little bit
Moderately
Quite a bit
Extremely

SF36V
8. During the past 4 weeks, how much of the time: (Select the single best answer for each question)
None
A little
Some
A good
Most
All
of the
of the
of the
bit of the
of the
of the
time
time
time
time
time
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?

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 friends, relatives)?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
SF36V

10. Please choose the answer that best describes how true or false each of the following statements is for you.
Definitely
Mostly
Not
Mostly
Definitely
SF36V
true
true
sure
false
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
SF36V
11. Compared to 3 years ago, how would you describe 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 describe 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
SF36V

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
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13. What is your current relationship 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 in a committed relationship or married, taking things all together, how would you describe your
relationship with your significant other?
Very unhappy

Very happy

NSFH

Comment [JLW1]: Web only. Only those that
indicate married or in a committed relationship.

16. I feel that I can trust my partner completely.
Very strongly disagree
Dyadic Trust Scale
Strongly disagree
Mildly disagree
Neutral
Mildly agree
Strongly agree
Very strongly agree

17. How happy are you with the following aspects of your relationship?
Very
Somewhat
N/A
Unhappy
Unhappy
unhappy
The understanding you
receive from your
partner
The love and affection
you get from your
partner
The amount of time you
spend with your partner

NSFH

Neither happy
or unhappy

Somewhat
happy

Happy

Very
Happy

Comment [JLW2]: Web only. Will be only for
those that indicate that they are in a committed
relationship or married.

Your partner as a
parent

18. In the last year, have you or your current spouse seriously suggested the idea of divorce or permanent separation?
No
Yes

Comment [JLW3]: Web only. Only those that
indicate married.

19. 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)

20. In general, how well do you feel you are coping with the day-to-day demands of parenthood/raising children?
Very well Somewhat well
Fair
Poorly
Very poorly
NSCH

Comment [JLW4]: Web only. Only those that
indicate children would see this.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

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RCS EXPIRATION DATE: XX/XX/XXXX

21. What is the highest level of education that you have completed? Choose the single best answer.
Less than high school completion/diploma

Associate’s degree

High school degree/GED/or equivalent

Bachelor’s degree

Some college, no degree

Master’s, doctorate, or professional degree

22. 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) ___________________

23. How tall are you? For example, a person who is 5’8” should write 5 feet 8 inches……… ___ feet ___ ___ inches

24. What is your current weight? …………………………………………………………... ___ ___ ___ pounds

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
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If YES, in what
year were you
first
diagnosed?

25. In the last 3 years, has your doctor or other health professional
told you that you have any of the following conditions

Yes

__ __ __ __

High cholesterol requiring medication

Yes

__ __ __ __

Coronary heart disease

Yes

__ __ __ __

Heart attack

Yes

__ __ __ __

Angina (chest pain)

Yes

__ __ __ __

Chronic bronchitis

Yes

__ __ __ __

Emphysema

Yes

__ __ __ __

Asthma

Yes

__ __ __ __

Kidney failure requiring dialysis

Yes

__ __ __ __

Pancreatitis

Yes

__ __ __ __

Gestational diabetes (diabetes during pregnancy)

Yes

__ __ __ __

Diabetes or sugar diabetes

Yes

__ __ __ __

Yes

__ __ __ __

Yes

__ __ __ __

Yes

__ __ __ __

Hepatitis C

Yes

__ __ __ __

Cirrhosis

Yes

__ __ __ __

Depression

Yes

__ __ __ __

Schizophrenia or psychosis

Yes

__ __ __ __

Manic depressive/bipolar disorder

Yes

__ __ __ __

Posttraumatic stress disorder

Yes

__ __ __ __

Thyroid condition other than cancer

Yes

__ __ __ __

Cancer

Yes

__ __ __ __

Gallstones
Kidney stones

Hepatitis B

Please Specify

Hypertension (high blood pressure)

Mark here if you
were hospitalized
for the condition in
the last 3 years.

Comment [JLW5]: Web will include 2 drop
downs with a list of the most common cancers and
an ‘other’ option and an open text field.

___________________________

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OMB EXPIRATION DATE: XX/XX/XXXX

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Q 25 continued……
If YES, in what
year were you
first
diagnosed?
No

Yes

__ __ __ __

Ulcerative colitis or proctitis

Yes

__ __ __ __

Acid reflux/gastroesophageal reflux disease
requiring medication

Yes

__ __ __ __

Significant hearing loss

Yes

__ __ __ __

Significant vision loss even with glasses or
contact lenses

Yes

__ __ __ __

Tinnitus/ringing of the ears

Yes

__ __ __ __

Memory loss or memory impairment

Yes

__ __ __ __

Migraine headaches

Yes

__ __ __ __

Yes

__ __ __ __

Traumatic brain injury (Do not include injuries that
resulted in only a concussion)

Yes

__ __ __ __

Neuropathy caused reduced sensation in the
hands or feet

Yes

__ __ __ __

Yes

__ __ __ __

Fibromyalgia

Yes

__ __ __ __

Rheumatoid arthritis

Yes

__ __ __ __

Degenerative joint disease/osteoarthritis

Yes

__ __ __ __

Yes

__ __ __ __

Yes

__ __ __ __

Yes

__ __ __ __

Crohn’s disease

Yes

__ __ __ __

Sleep apnea

Yes

__ __ __ __

Anemia

Yes

__ __ __ __

Infertility

Yes

__ __ __ __

Parkinson’s disease

Yes

__ __ __ __

Alzheimer’s disease

Yes

__ __ __ __

Sexual dysfunction

Yes

__ __ __ __

Other (please specify)

Yes

__ __ __ __

Stroke

Lupus
Multiple sclerosis

Seizures

Stomach, duodenal, or peptic ulcer

Chronic fatigue syndrome

Mark here if you
were hospitalized
for the condition in
the last 3 years.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

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26. During the past 12 months, on average, how often did you have any symptoms of asthma apart from a cold or
respiratory infection? (e.g. cough, wheezing, shortness of breath, chest tightness and phlegm production).
Not at any time
Less than once a week
Once or twice a week
More than 2 times a week, but less than daily
Every day, but only during certain seasons
Every day, all the time

Comment [JLW6]: Web only.

27. During the past 12 months, which of the following describes your level of asthma symptoms (mark all that apply).
I’ve not been troubled by asthma during the past 12 months
I’ve had mild symptoms for which I have not taken any asthma medication
I’ve had symptoms requiring asthma medication
I’ve had symptoms requiring an urgent visit to a doctor or emergency care
I’ve had symptoms requiring me to stay overnight at a hospital

28. In the last 3 years, have you had persistent or recurring problems with any of the following?

Comment [JLW7]: Web only.

Sea Bee

Yes

Night sweats

Yes

Sore throat

Yes

Unusual muscle pain

Yes

Frequent bladder infections

Yes

Unusual fatigue

Yes

Cough

Fever

Sudden Unexplained hair loss

Rash or skin ulcer

Yes

Forgetfulness

Yes

Confusion

Yes

Trouble Sleeping

Yes

29. Please describe your prior history and or current symptoms of low back pain (choose one option). I
have never had low back pain
Skip to question xx
I have had low back pain, but not in the past 6 months
Skip to question xx
In the past 6 months, I have had low back pain on less than half the days
In the past 6 months, I have had low back pain on at least half the days
In the past 6 months, I have has low back pain every day or nearly every day

30. If you have had low back pain in the past 6 months, how long have your most recent symptoms of low back pain
been a problem for you?
I have not had low back pain in the past 6 months
Less than 1 month
1 to 3 months
4 to 6 months
7 months to less than 1 year
1 to 3 years
4 or more years
31. Have you had pain, aching or stiffness in or around your knee(s), on at least half the days in the past month?
No, I have not had symptoms in either knee
Yes, in my left knee
Yes, in my right knee
Yes, in both knees
32. Over the past 3 years, approximately how many days were you hospitalized because of illness or injury? (Excluding
lost time for pregnancy and childbirth)
__ __ __ __ days

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

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33. Over the past 3 years, approximately how many days were you unable to perform your usual activities because of
illness or injury? (Excluding lost time for pregnancy and childbirth)
__ __ __ __ days

Sea Bee
34. During the last 4 weeks, how much have you been bothered by any of the following problems?
Not
Bothered a Bothered a
bothered
little
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. Little to no sexual desire
o. Women only: menstrual cramps or other problems with your periods

35. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at
all

a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless

Several
days

PHQ

More than half
the days

Nearly every
day

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 a-h 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

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
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36. Over the last 2 weeks, how often have you been bothered by the following problems?

GAD 7

Not at all

Several
days

More than half
the days

Nearly every
day









a. Feeling nervous, anxious or on edge
b. Not being able to stop or control worrying
c. Worrying too much about different things
d. Trouble relaxing
e. Being so restless that it is hard to sit still
f. Becoming easily annoyed or irritable
g. Feeling afraid as if something awful might happen

37. On an average day, how many 8-12 oz beverages containing caffeine do you drink?
1-2 per day
3-5 per day
6-10 per day
11 or more per day
None

RAP

PHQ
38. Do you often feel that you can’t control what or how much you eat?
b. Do you often eat, within any 2 hour period, what most people would regard as an unusually
large amount of food?
c. If you marked YES to either of the above, has this been as often, on average, as once a week for
the LAST 3 MONTHS?

39. FOR WOMEN ONLY:

a.
b.

How old were you when your menstrual periods began?
○ 9 or less
○ 10
○ 11
○ 12
○ 13
Have you ever been pregnant? ○ No ‐ skip to question 42h

Are you currently pregnant?

○ No

○ 14

Yes

Comment [JLW8]: Web only

○ Yes

How many births (live born children or stillbirths) have you had? __
Have you given birth within the last 3 years?

How old were you when you first gave birth? __ years old

How many months in total did you breastfeed (total for all children)?
○ 3‐5 months
○ 6‐11 months
○ 12‐17 months
○ Less than 3 months

○ No

(If 0, skip to question X)

○ Yes

○ 18 or more months

Yes

○ 15
○ 16
○ 17 or more
○ Yes → How many mes? __

Have you ever used oral contraceptives (birth control pills)?
(If no, skip to question 37)
○ No
○ Yes → Age when first used
__ years old Age when last used __ years old
How many years in total have you used birth control pills (exclude time periods when you temporarily stopped)?
○ 5‐9
○ 20 or more
○ Less than 1 year
○ 1‐2
○ 3‐4
○ 10‐19

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

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40. Indicate the degree to which each statement describes your feelings or behavior:

None or
almost none
of the time

DAR5

A little
of the
time

Some
of the
time

Most of
the
time

All or
almost all
of the time

a. I often find myself getting angry at people or situations
e. My anger prevents me from getting along with people as
well as I’d like to

41. How often in the past month did you get angry with someone and kick/smash something, get into a fight, hit someone
or threaten someone with physical violence?
Never
1 time
2 times
3-4 times
5 or more times

42. In the past 12 months, did you take any of the following medications regularly (at least once per week)?
Yes, please indicate total tablets per week.
1-2

3-5

6-14

15+

No, or less
than once
per week

Multivitamins
“Baby” or low dose aspirin (less than 100 mg)
Aspirin or aspirin-containing products (e.g. Bayer,
Excedrin)
Ibuprofen (e.g. Advil, Motrin)
Other over-the-counter pain relievers (e.g. Aleve,
Tylenol)
Prescription non-narcotic pain relievers (e.g. Celebrex)
Prescription narcotic pain relievers (e.g. Codeine,
OxyContin, Percocet, Vicodin)

43. In the last 12 months, how long did you take prescription narcotics for pain relief, such as Codeine, OxyContin,
Percocet, Vicodin?
Never Less than 1 week
1-2 weeks
3-4 weeks
More than 4 weeks

44. Over the past month, how many hours of sleep did you get in an average 24-hour period? Persian Gulf War Survey
__ __ hours

45. Pease rate your sleep pattern for the past 2 weeks. Insomnia Severity Index
None

Mild

Moderate

Severe

Very Severe

a. Difficulty falling asleep
b. Difficulty staying asleep
c. Problem waking up too early

46. How SATISFIED/dissatisfied are you with your current sleep pattern? Insomnia Severity Index
Very dissatisfied
Very satisfied
0
1
2
3
4

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

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47. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue,
ability to function at work/daily chores, concentration, memory, mood, etc.)? Insomnia Severity Index
Somewhat
Much
Very much interfering
Not at all interfering
A little

48. How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?

Insomnia Severity Index
Not at all noticeable

Barely

Somewhat

Much

Very much noticeable

49. How WORRIED/distressed are you about your current sleep problem? Insomnia Severity Index
Somewhat
Much
Very much
Not at all
A little
50. During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?

Pittsburgh Sleep Quality
Not at all during past month
Less than once a week
Once or twice a week
Three or more times a week

Best Practices

51. In the past 3 years, who have you had sex with?
Men only
Women only
Both men and women
I have not had sex
Prefer not to answer

NHIS & HEAR
52. 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.)
On those days,
# of days
how many
- None
- Cannot
per week
minutes per day
physically do
you exercise
on average do you
exercise
a. STRENGTH TRAINING or work that strengthens
__ days
__ __ __ minutes
your muscles? (such as lifting/pushing/pulling weights)
AND
OR
b. VIGOROUS exercise or work that causes heavy
__ days
sweating or large increases in breathing or heart rate?
AND __ __ __ minutes OR
(such as running, active sports, marching biking)
c. MODERATE or LIGHT exercise or work that causes
__ days
light sweating or slight increases in breathing or heart
AND __ __ __ minutes OR
rate? (such as walking, cleaning, slow jogging)

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

PCL‐C

53. 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
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

54. On a typical day, how much time do you spend sitting and watching TV or videos or using a computer? NHANES
__ __ hours per day

55. Have you used any of the following practices in the last 12 months? If YES, please indicate whether the following
were reasons you most recently received this treatment (mark all that apply)
Yes

For a condition
that lasted less
than one
month

For a condition
that lasted
more than one
month

To improve
well-being

Pain
management

Please Specify

________________

a. Acupuncture
b. Chiropractic
care
c. Spiritual
healing
d. Meditation



________________
________________
________________

56. If you answered YES to any item in question xx above, has your level of satisfaction with conventional medicine led
you to seek alternative health practices?
No
Yes

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

57. Have you taken any of the following supplements in the last 12 months?
No
a.
b.
c.
d.
e.

Yes

Hormones for muscular strength, enhancement, or performance (e.g. anabolic steroids)
Body building supplements (e.g. amino acids, weight gain products, creatine, etc.)
Energy drinks (e.g. Red Bull, Monster, Rock Star, etc.)
Energy supplements (e.g. energy pills or energy enhancing herbs)
Weight loss supplements (e.g. examples)

Mildly
Disagree

Neutral

Mildly
Agree

Strongly
Agree

58. Please indicate how you feel about each statement.
Very
Strongly
Strongly
Disagree
MSPSS
Disagree
a. There is a special person with whom I
can share my joys and sorrows.
b. My family really tries to help me.
c. I have a special person who is a real
source of comfort to me
d. My friends really try to help me
e. I can talk about my problems with my
family
f. I have friends with whom I can share my
joys and sorrows

To a
moderate
degree

To a
great
degree

To a
very
great
degree

59. Indicate the degree to which the following statements are true in your life: PTGI
To a
To a
very
Not
small
small
at all
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

Very
Strongly
Agree

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

60. Please indicate your level of agreement with these statements: Pearlin & Schooler
Strongly
disagree

Disagree

Neither
agree nor
disagree

Agree

Strongly
agree

a. I have little control over the things that happen to me
b. There is really no way I can solve some of the problems I
have
c. There is little I can do to change many of the important
things in my life.
d. I often feel helpless in dealing with the problems of life.
e. Sometimes I feel that I am being pushed around in life.
f. What happens to me in the future mostly depends on me
g. I can do just about anything I really set my mind to do

61. In the last 12 months, did you seek care for any of the following?
Number of therapy*
sessions attended. If
None, write 0

Are you or did you
take medication for
this?

a. Posttraumatic stress disorder (PTSD) or
posttraumatic stress (PTS) symptoms

__ __ __

‫ס‬

b. Anxiety

__ __ __

‫ס‬

__ __ __

‫ס‬

__ __ __

‫ס‬

__ __ __

‫ס‬

__ __ __

‫ס‬

Depression

d. Stress
e. Anger
f.

Yes

Substance use

g. Relationship/family issues

__ __ __
‫ס‬
*Therapy sessions are individual or group meetings to treat symptoms without or in addition to medication.

62. Are you worried or concerned that in the next 2 months you may NOT have stable housing that you own, rent, or stay
in as part of a household?
HSCR
No
Yes

63. At any time in the last 6 years have you found it necessary to sleep in a shelter, on the streets or in another nonresidential setting because of having no other place to stay? (Please only refer to instances during or after military
service)
No
Yes
b. If YES, please indicate the dates of your most recent situation:
M M /Y Y to M M/Y Y

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
64. In the past year, did you drink any type of alcoholic beverage?
No
Yes
If you marked NO, skip to question xx

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

65. In the past year, on those days that you drank alcoholic beverages, on average, how many drinks did you have?

NHIS
__ __ drinks

66. Last week, how many drinks of alcoholic beverages did you have? (If NONE, please enter 0) NHIS
__ __
__ __
__ __
__ __
__ __
__ __
__ __
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

67. In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage? NHIS
v
(If NONE, please enter 0)
__ __ __ days

68. 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?

NIAAA Taskforce
Monthly or less

2-4 times a month

>4 times a month

Never

69. 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?

NIAAA Taskforce
Never

Monthly or less

2-4 times a month

>4 times a month

70. In the last 12 months, have any of the following happened to you more than once? PHQ

Yes

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
c. You missed or were late for work, school, or other activities because you were drinking or hung
over
d. You had a problem getting along with people while you were drinking
e. You drove a car after having several drinks or after drinking too much

71. In the past 12 months, have you felt any of the following? CAGE
a.
b.
c.
d.

Felt that you needed to cut back on your drinking
Felt annoyed at anyone who suggested you cut back on your drinking
Felt you needed an “eye-opener” or early morning drink
Felt guilty about your drinking

72. In the past year, have you used any of the following tobacco products? Persian Gulf War Survey
No
a. Cigarettes (smoke)
b. Electronic cigarettes or vape products
c. Cigars
d. Pipes
e. Smokeless tobacco (chew, dip, snuff)

Yes

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

73. In your lifetime, have you smoked at least 100 cigarettes (5 packs)? Sea Bee

Yes

If you marked NO, skip to question XX
Questions xx-xx refer to smoking CIGARETTES and not electronic cigarettes or vaping
74. At what age did you start smoking? Persian Gulf War Survey

__ __ years old

75. How many years have or did you smoke an average of at least 3 cigarettes per day (or one pack per week)?
__ __ years
76. Do you CURRENTLY smoke cigarettes?
No, not at all
Yes, every day

Yes, some days

77. 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

More than 2 packs per day

78. Have you ever tried to quit smoking? RAP
Yes, but not successfully
Yes, and succeeded

RAP
1 to 2 packs per day

79. Do you CURRENTLY use electronic cigarettes or vape products?
No, not at all
Yes, every day
Yes, some days

Comment [JLW9]: Web only

80. Have you used electronic cigarettes or vape products in the past? (More than a year ago)
No, not at all
Yes, every day
Yes, some days

Comment [JLW10]: Web only

81. In the past month have you experienced…?

PCL‐5
Not at all

A little bit

Moderately

Quite a bit

Extremely

a. Having strong negative beliefs about yourself, other
people, or the world (for example, having thoughts such
as: I am bad, there is something seriously wrong with
me, no one can be trusted, the world is completely
dangerous)

b. Blaming yourself or someone else for a stressful
experience or what happened after it

c. Having strong negative feelings such as fear, horror,
anger, guilt, or shame
d. Taking too many risks or doing things that could
cause you harm
e. Trouble experiencing positive feelings (for example,
being unable to feel happiness or having loving feelings
for people close to you)

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

82. In the past 3 years, have any of the following life events happened to you? Persian Gulf War Survey
If YES, list
most recent year
No
Yes
a. You moved or changed residence more than once
201_
b. You changed jobs, assignment, or career path involuntarily (for example,
you lost a job, or you had to take a job you did not like)
201_
c. You or your partner had an unplanned pregnancy
201_
d. You were divorced or separated
201_
e. Suffered major financial problems (such as bankruptcy)
201_
f. Suffered forced sexual relations or sexual assault*
201_
g. Experienced sexual harassment*
201_
h. Hazing/initiation rituals
201_
i. Experienced harassment (other than sexual harassment)
201_
j. Experienced discrimination
201_
k. Suffered a violent assault
201_
l. Had a family member or loved one who became severely ill
201_
m. Had a family member or loved one who died
201_
n. Suffered a disabling illness or injury
201_
o. Experienced infidelity or unfaithfulness in a committed relationship
201_

Most recent experience ‐ YYYY

83. a. While serving in the military, how often have you had unwanted experiences where a person(s) sexually touched
you (e.g., intentional touching of genitalia, breasts, or buttocks), made you sexually touch them, attempted to or
actually made you have sexual intercourse/oral or anal sex (or sexual penetration with finger/object) without your
consent?"
Never Once Twice A few times Many times

84. During this experience, did the offender(s): (Response for each item is yes/no)
Take advantage of you when you couldn't defend yourself (e.g., too drunk/high or asleep)?
Use physical force/violence, or threaten you/someone close to you with physical harm?

Comment [JLW11]: Web only will see
additional questions
Comment [JLW12]: Web only will see
additional questions

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

*You indicated that you suffered a forced sexual relation or sexual assault within the past 3 years. This section asks additional
questions about these experiences. We are aware that many of these questions are quite personal. Your answers are strictly
confidential and will not be used to identify any persons.
In the past 3 years, have you suffered a forced sexual relation or sexual assault?
Once with one person
No
Once with multiple people
No
More than once with the same person
No
More than once with multiple people
No
Not sure
No

Comment [JLW13]: Web only sexual assault
questions

Yes
Yes
Yes
Yes
Yes

*For the following questions, we’d like you to think about the sexual assault, or, if you experienced more than one sexual assault in
the past three years, the one sexual assault incident that had the greatest impact on you:
No
No
No

Yes
Yes
Yes

Yes

No
No

Yes
Yes

Where did the incident occur?
At a military installation?
At a civilian location?
During your work day/duty hours?
While you were on TDY/TAD, at sea, during field
exercises/alerts, or any type of military combat training?
While you were deployed to a combat zone or to an area
where you drew imminent danger pay or hostile fire pay?
During military schooling*?
*(e.g., Officer Candidate School, Basic or Advanced Officer
Course, basic military training, occupational specialty school /
technical training, or advanced individual training/
professional military education)

At the time that the incident occurred, was the offender(s)...
Someone in your chain of command?
Other military person(s) of higher rank/grade who was/were not
in your chain of command?
Your military coworker(s)?
Other military person(s)?
DoD/Service civilian employee(s) or contractor(s)?
Your spouse/significant other?
Other civilian person(s) (e.g. friend(s), relative(s),
acquaintance(s))
Unknown person(s)/don't know?

Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No

Yes
Yes

What was the gender(s) of the offender(s)?
Male only
Female only
Both male and female
Not sure

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

*You indicated that you suffered sexual harassment within the past 3 years. This section asks additional
questions about these experiences. We are aware that many of these questions are quite personal. Your answers
are strictly confidential and will not be used to identify any persons.
In the past 3 years, have you suffered sexual harassment?
Once with one person
No
Once with multiple people
No
More than once with the same person
No
More than once with multiple people
No
Not sure
No

Yes
Yes
Yes
Yes
Yes

For the following questions, we’d like you to think about the sexual harassment situation, or, if
you experienced more than one sexual harassment incident in the past three years, the one
sexual harassment incident that had the greatest impact on you:

*(e.g., Officer Candidate School, Basic or Advanced Officer
Course, basic military training, occupational specialty school /
technical training, or advanced individual training/
professional military education)

No
No
No

Yes
Yes
Yes

Yes

No
No

Yes
Yes

Yes

No
No
No
No
No

Yes
Yes
Yes
Yes
Yes

No
No

Yes
Yes

Comment [JLW14]: Web only sexual
harassment questions

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

85. During the past 3 years, have you been PERSONALLY exposed to any of the following?
(Do not include TV, video, movies, computers, or theater) Persian Gulf War Survey

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

Yes, 1
time

Yes, more than 1 time

If YES, list most
recent year of
exposure



201__



201__





201__
201__
201__

86. During any military deployment, were you EVER exposed to any of the following?
If YES, please indicate how often and how long you were exposed



Daily

Weekly

Monthly

Less than once
per month

For how many months
were you exposed



__ __



__ __



__ __



__ __



__ __

 



__ __

 



__ __

 



__ __

 

a. Exhaust fumes (from
engine or jet fuels)
b. Sand or dust storms
c. Ionizing radiation
(requiring a personal
monitoring device)
d. Munitions disposal
e. Chemical or biological
warfare agents
f. Medical
countermeasures for
chemical or biological
warfare agent exposure
g. Alarms necessitating
wearing of chemical or
biological warfare
protective gear
h. Smoke from burning
trash and/or feces

Yes

87. Are you currently serving in the US military?
Yes, Active duty
 Yes, Reserve or National Guard

No

88. a. Since 2010 did you retire, separate or leave the service for any reason?
Yes
Noskip to question xx
b. What was your date of separation or retirement from the military?

M M/ Y Y

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

c. What was the reason for your separation/retirement from the military?
Planned separation
Unplanned administrative separation
(end of service term/retirement)
(e.g. military downsizing, failure to promote, failure to
Medical separation
meet service standards)
Disciplinary separation
Other (e.g. pregnancy, parenthood, educational
pursuits)

Quite a
bit

Extremely



89. How much did each of the following reasons affect your decision to leave the military?
Not at
A little
Moderately
all
bit
a. Desire to continue your education, start a new



career, or change in personal goals
b. Disability or other medical reasons



c. Difficulty meeting weight standards and/or fitness



standards
d. Incompatibility with the military



e. Legal problems or problems meeting a military



obligation
90. a. Has the VA determined that you have one or more service connected disabilities?
No
Yes
Pending determination
N/A

1. If YES, indicate the total percent of you VA service‐connected disabilities………….. ___ ___ ___ % disability

91. In the last 3 years, how much of your medical care, if any, have you received from the Department of Veterans
Affairs/Veterans Health Administration facilities?
None
Very little
Some
Most
All of my care

92. What kind of health coverage or insurance do you currently have? (Check all that apply)
No insurance
Medicaid
VA health care
Medicare
Tricare or military health insurance
Other insurance (from employer or school)

93. Have you deployed or been on a deployment at any time* in the past 3 years? (WEB: ….since “anchor date”)
No  Go to Question xx
Yes

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

94. In the last 3 years, how often have you experienced the following during deployment?






List most
recent year
of exposure
 2 0 1 ___
 2 0 1 ___
 2 0 1 ___
 2 0 1 ___



 2 0 1 ___



















Never 1 time

2 0 1 ___
2 0 1 ___
2 0 1 ___
2 0 1 ___
2 0 1 ___
2 0 1 ___
2 0 1 ___
2 0 1 ___

a. Feeling that you were in great danger of being killed
b. Being attacked or ambushed
c. Receiving small arms fire
d. Cleaning/searching homes or buildings
e. Having an improvised explosive device (IED) or booty trap explode
near you
f. Being wounded or injured
g. Seeing dead bodies or human remains
h. Handing or uncovering human remains
i. 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 an enemy combatant
m. Being directly responsible for the death of a non‐combatant

More than
1 time

95. Based on your most recent duty assignment, please indicate how much you agree or disagree for each item.
Neither
Strongly
Strongly
Disagree agree or
Agree
DRRI
agree
disagree
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






Comment [JLW15]: Web only. Everyone except
those that separated MORE than 3 years ago would
answer.

96. a. How often did you communicate with your spouse during your last completed deployment?
Almost daily At least once a week Every other week
Once a month Less than once a month

Comment [JLW16]: Web only. Only those that
indicate that they are currently married would see
this question.

b. Overall, when you communicated with your spouse during your last completed deployment how satisfied
were you with your ability to support each other (connect emotionally and/or spiritually)?
Very satisfied 1
2
3
4
5
Very dissatisfied

97. How satisfied are/were you with each of the following aspects of your military service?
Neither
Very
N/A
Satisfied
satisfied or
satisfied
dissatisfied
a. Pay and housing allowance




b. Medical/health care for you and




your family
c. Pace of promotions/chance for




advancement
d. Frequencies of




deployments/unaccompanied tours
e. Time with family




f. Impact on spouse’s employment and




career opportunities

Dissatisfied

Comment [JLW17]: Web only. Only those that
indicate that they are currently married would see
this question.

Very
dissatisfied
























22

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

The questions below are about your most recent head injury.
98. In the past 3 years, have you had an injury, such as from a fall, blow to the head, blast exposure, motor vehicle
crash, sports, or any other cause that resulted in any of the following?
No
Yes
Don’t know
a. Being dazed right after the injury?
 

 

b. Being confused or not thinking clearly right after the injury?
c. Not remembering the actual injury right after it happened?
 

d. Not remembering things that happened right after the injury?
 

e. Losing consciousness or being knocked out?
 

99. If YES to any item in question xx above, how many total injuries have occurred in the past 3 years?
During the service
___ ___ injuries
After leaving the service
___ ___ injuries
If you answered YES to any item in question xx above, please describe the most recent injury event.
For the most recent injury that resulted in being dazed, confused, not remembering, etc.:
a. Was this your most serious injury that resulted in being dazed, confused, not remembering, etc.?
No
Yes
b. When did it happen? (mm/yy)

100.

__ __ / __ __

c. Were you deployed when the injury happened?
No
Yes

d. What caused the injury? (Please choose the single best answer)
Blast/explosion
Military training
Bullet/fragment
Playing sports/recreation activity/PT
Motor vehicle crash
Fall

Fighting with someone
Other
Don‘t know

e. Right after the injury, were you dazed?
No
Yes
Don‘t know

e1. If YES, how long did it last?
Less than 1 minute
1 minute but less than 10 minutes
10 minutes but less than 30 minutes

30 minutes but less than 24 hours
24 hours or more
Don‘t know

f. Right after the injury, were you confused or not thinking clearly?
No
Yes
Don‘t know
f1. If YES, how long did it last?
Less than 1 minute
1 minute but less than 10 minutes
10 minutes but less than 30 minutes

30 minutes but less than 24 hours
24 hours or more
Don‘t know

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

g. Did you lose memory about things that happened right before the injury?
h. Were you unable to remember the actual injury itself?
i. Were you unable to remember things that happened right after the injury?

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

No




Yes




Don’t know




j. If you had memory gaps or could not remember the injury, how long was it after the injury before you started
remembering NEW things again?
Less than 1 hour
7 days or more
1 hour to 24 hours
Don’t know
More than 24 hours but less than 7 days
k. Did anyone tell you that you seemed dazed or confused, talked or acted oddly, and/or did not make sense after the
injury?
Don‘t know
No
Yes
l. Were you unconscious or knocked out?
No
Yes
Don‘t know

l1. If YES, how long were you unconscious or knocked out?
Less than 1 minute
30 minutes but less than 24 hours
1 minute but less than 10 minutes
24 hours or more
10 minutes but less than 30 minutes
Don’t know
m. After the injury, did anyone tell you that you were lying unresponsive, not opening your eyes, or not responding in
any way?
No
Yes
Don‘t know
n. When this injury happened, were any parts of your body injured OTHER THAN your head?
No
Yes
Don‘t know
o. Did this injury disrupt your personal and/or work activities for more than 1 day?
No
Yes
Don‘t know

p. Did you get a medical evaluation/treatment for this injury?
No
Yes
Don‘t know

p1. If YES where did you get evaluated/treated? (Check all that apply)
In the field by a medic
Outpatient clinic/doctor’s office
Emergency room/urgent care center
Admitted to the hospital as an INPATIENT  how many nights __ __ __
Don’t know

101.

Within the last 3 years, how many motor vehicle accident(s)/crash (es) have you been in while NOT deployed?
___ ___ accidents/crashes
If NONE, skip to question XXX

b. List the date of your most recent motor vehicle accident/crash (mm/yy)

__ __ / __ __

c. What is the total number of work days lost as a result of this motor vehicle accident/crash:

___ ___ ___ ___ days
24

Comment [JLW18]: Web only.

OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX

RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX

d. What treatment did you seek for your injuries from this motor vehicle accident/crash?
No treatment sought

102.

Clinic or office visit only

Hospitalized: number of days…___ ___ ___ ___

What is your annual household income? Please choose only one.
Less than $25,000
$75,000 – $99,999
$125,000 – $149,999
$25,000 – $49,999
$100,000 – $124,999
$150,000 or more
$50,000 – $74,999
Which best describes the financial condition of you and your family? Please choose only one.
Very comfortable and secure
Able to make ends meet without much difficulty
Occasionally have some difficulty making ends meet
Tough to make ends meet but keeping our heads above water
In over our heads

104.

Has someone assisted you with filling out this survey?
No
Yes

103.

Address: ______________________________________________________________ Apt/Suite: _________________
City (of FPO/APO): ____________________________________________ State/Province Region (or AA/AE/SP): ________
Zip/Postal Code: ____________________________

Country: ___________________________________

Please provide your phone number(s): (Separate multiple phone numbers with a space)

106.

Please provide your email address(es): (Separate multiple email addresses with a space)

107.

What year were you born?

105.

108.

What are the last four digits of your Social Security Number?

109.

What is today’s date (mm/dd/yyyy)

___ ___ ___ ___
___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___

110.
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.) Do not include any Personally Identifiable Information (PII).

File Type	application/pdf
File Title	Microsoft Word - 2017_Follow Up_Survey_Sourced.docx
Author	Jennifer.Walstrom
File Modified	2018-04-23
File Created	2015-12-21