Millennium Cohort Baseline 2017 Survey
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The text in red on the following survey document indicates the source of the survey question.
OMB CONTROL NUMBER: 0703-0064
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Consent Form
What is the study about?
You are being asked to be a volunteer in a research study called "The Millennium Cohort Study" conducted by the
US Department of Defense (DoD). This study will follow the long-term health of military personnel during and after
their military service. The purpose is to assess the health outcomes of military deployment, military occupations,
and general military service. You have been scientifically selected to represent your service branch, gender,
service type, military occupation, and age group from among the over two million military personnel serving as of
XXXXX in the regular Active Duty, Reserve, and National Guard forces. Your participation will help determine
the long-term health effects of military service, define healthcare policy for future generations of service
members, and guide prevention and treatment programs for years to come.
What will participation involve?
You are being asked to do the following:
FT
Complete the attached survey today. You are also being asked to complete X follow-up surveys over XX years,
with one survey to complete every three years. Filling out the survey will take about 45 minutes each time you
complete it. The surveys contain questions on a broad range of health topics, including medical conditions, health
behaviors, and exposures that may affect your health. We will connect your survey data with other data, medical
records, or biomarkers collected and maintained by the Department of Defense, Department of Veterans Affairs
health care, disability, and other databases, or federal and state agencies. Additionally, you may be asked to
participate in other sub-studies and if you so choose may involve a variety of tests including neurocognitive
testing and blood samples. You will be contacted semi-annually to verify your contact information. In addition,
there is a 3% random chance that you will be contacted by telephone for focus group testing. You are one of
approximately XXXXXX volunteers who are being asked to participate in this very important study.
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What risks are involved in the study?
The data collection procedures are not expected to involve any risk or discomfort to you. The main risks to you
are those associated with the inappropriate disclosure of data that we collect from or about you. While
inappropriate disclosure has the potential to impact your reputation, insurability, or employability, it is important for
you to understand that this research group has collected similar information from numerous studies over many
years without any cases of inappropriate disclosure. There is also the risk of possible discomfort from answering
some sensitive questions, but you may skip any question(s) that make you uncomfortable. If you feel that you
might need medical care or counseling you should make contact with the appropriate health care personnel.
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How will your data be protected against those risks?
All questionnaires will be kept in locked files. When your data are entered into computer files for analysis, your
answers will be identified only by a special study identification number known to you and research team
members. This number is located on the barcode of your study envelope and survey. Your social security number
and any other personal identification information will be removed from your questionnaire and data file upon
return to the researchers. Even if someone outside the research team broke into the files, it would be impossible
for them to identify your data. To minimize the risk of anyone breaking into the data files, those files will be
maintained on DoD computers protected by all the measures required by DoD computer security regulations. All
members of the research team with access to data files will be trained in DoD computer security procedures
specifically designed to protect sensitive data. Reports of the study findings will contain only group data, so that
no individual study participant can be identified. Similar procedures have been used to protect data in previous
studies conducted within this research center.
According to the DoD Policy "Interim Regulations to Improve Privacy Protections for DoD Medical Records" dated
October 31, 2000, the information you provide is for research purposes only and may not be disclosed except for
specifically authorized purposes or with the consent of the individual about whom the information pertains. Uses
and disclosures of this information shall comply with provisions of the Privacy Act and implementing regulations.
continued on page 2...
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continued from page 1...
How is your information protected if you complete the questionnaire using the Internet web site option?
All information collected through the Internet questionnaire option is done by using Secure Sockets Layer (SSL)
data transmission lines. SSL encrypts, or scrambles, all questionnaire data sent over the Internet. Information will
only be understandable when it reaches the investigator database. The same methods of protection listed above
will then be followed to further protect your information.
What are the benefits of participating in the study?
While your participation in this study will not directly benefit you, your participation will help define health care
policyfor future generations of military personnel and guide prevention and treatment programs for years
to come.
Do you have to participate?
FT
No, you do not! Your participation must be completely voluntary. If you decide to participate, you can stop at any
time you wish or skip any question you choose. If you choose not to participate or to discontinue your
participation, you will not lose any benefit to which you are otherwise entitled. You may change your mind and
revoke your permission to further collect or use your health information at any time. If you revoke your permission,
no new health information about you will be gathered after that date. However, unless specified otherwise,
information that has already been gathered may still be used for analyses. Collected data will be maintained until
all research questions are answered. To end participation, contact the principal investigator at
[email protected], or (888) 942-5222.
Your participation may also be ended by the investigators. While this is not anticipated, available funding or other
logistical considerations could conceivably result in the early termination of this study.
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Who can provide additional information if you need it?
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Questions about the research (science) aspects of this study should be directed to the principal investigator of the
Millennium Cohort Study at [email protected] or (888) 942-5222. You may also refer to the web site at
www.MillenniumCohort.org for more information. Questions about the ethical aspects of this study, your rights as
a volunteer, or any problem related to the protection of research volunteers should be directed to Christopher G.
Blood, JD, MA, Chairperson, Institutional Review Board, Naval Health Research Center, at telephone (619) 5538386 or by email at [email protected].
.
Where can you find your records if you wish to review them?
The principal investigator will be responsible for storing the consent form and other research records related to
this study. The records will be stored at the Deployment Health Research Department, Naval Health Research
Center, 140 Sylvester Road, San Diego, CA 92106. You can review your surveys until the study ends by
contacting the principal investigator at [email protected], or (888) 942-5222
Voluntary Consent
I consent to participate in the study described above. My consent is completely voluntary and is based solely
on the information provided in this consent form.
Volunteer's signature
Date (mm/dd/yy)
Volunteer's printed name (first, middle initial, last)
OMB CONTROL NUMBER: 0703-0064
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Privacy Act Statement
You have rights under the Privacy Act.
The following statement describes how that ACT applies to this study:
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 [insert date here]and can be found by
visiting:
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
RCS EXPIRATION DATE: XX/XX/XXXX
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
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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
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? SF36V
No, not
at all
Yes, limited
a little
Yes, limited
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
j.
Bathing or dressing yourself
FT
d. Climbing several flights of stairs
D
A
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? SF36V
No,
Yes,
Yes,
Yes,
Yes,
none of a little of some of
most of
all of
the time the time the time the time the time
a. Cut down the amount of time you spent on work or
other activities
b. Accomplished less than you would like
c. Were limited in the kind of work or other activities
d. Had difficulty performing the work or other activities
(for example, it took extra effort)
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)? SF36V
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? SF36V
Moderately
Quite a bit
Extremely
Not at all
Slightly
6. During the past 4 weeks, how much bodily pain have you had? SF36V
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)?
SF36V
Moderately
Quite a bit
Extremely
Not at all
A little bit
A
FT
8. During the past 4 weeks, how much of the time: (Select the single best answer for each question) SF36V
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)? SF36V
Some of the time
Most of the time
All of the time
None of the time
A little of the time
D
10. Please choose the answer that best describes how true or false each of the following statements is for you. SF36V
Definitely
Mostly
Not
Mostly
Definitely
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
11. Compared to 3 years ago, how would you describe your physical health in general now? SF36V
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? SF36V
Much better
Somewhat better
About the same
Somewhat worse
Much worse
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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
1
2
3
4
16. I feel that I can trust my partner completely.
Strongly disagree
Disagree
Moderately disagree
Neither agree nor disagree
Moderately agree
Agree
Strongly agree
5
6
7
Very happy
NSFH
Comment [JLW1]: Web only. Only those that
indicate married or in a committed relationship.
Dyadic Trust Scale
NSFH
FT
17. How happy are you with the following aspects of your relationship?
Somewhat
Very
Unhappy
N/A
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
Your partner as a
parent
Somewhat
happy
Happy
Very
Happy
A
Neither happy
or unhappy
18. In the last year, have you or your current spouse seriously suggested the idea of divorce or permanent separation?
No
Yes
Comment [JLW2]: Web only. Will be only for
those that indicate that they are in a committed
relationship or married.
Comment [JLW3]: Web only. Only those that
indicate married.
D
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.
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
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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
D
A
FT
24. What is your current weight? …………………………………………………………... ___ ___ ___ pounds
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25. Has your doctor or other health professional ever told you that you have
any of the following conditions?
If YES, in what
year were you
first
diagnosed?
No
Yes
__ __ __ __
High cholesterol requiring medication
No
Yes
__ __ __ __
Coronary heart disease
No
Yes
__ __ __ __
Heart attack
No
Yes
__ __ __ __
Angina (chest pain)
No
Yes
__ __ __ __
Chronic bronchitis
No
Yes
__ __ __ __
Emphysema
No
Yes
__ __ __ __
Asthma
No
Yes
__ __ __ __
Kidney failure requiring dialysis
No
Yes
__ __ __ __
Pancreatitis
FT
Hypertension (high blood pressure)
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
Schizophrenia or psychosis
No
Yes
__ __ __ __
Manic depressive/bipolar disorder
No
Yes
__ __ __ __
Posttraumatic stress disorder
No
Yes
__ __ __ __
Thyroid condition other than cancer
No
Yes
__ __ __ __
Cancer
No
Yes
__ __ __ __
Gestational diabetes (diabetes during pregnancy)
Diabetes or sugar diabetes
Gallstones
Kidney stones
A
Hepatitis B
Hepatitis C
Cirrhosis
D
Depression
Please Specify
Mark here if you
were ever
hospitalized for
the condition
Comment [JLW5]: Web will include 2 drop
down list with a list of the most common cancers
and an ‘other’ option and an open text field.
___________________________
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Q 25 continued……
If YES, in what
year were you
first
diagnosed?
No
Yes
__ __ __ __
Ulcerative colitis or proctitis
No
Yes
__ __ __ __
Acid reflux/gastroesophageal reflux disease
requiring medication
No
Yes
__ __ __ __
Significant hearing loss
No
Yes
__ __ __ __
Significant vision loss even with glasses or
contact lenses
No
Yes
__ __ __ __
Tinnitus/ringing of the ears
No
Yes
__ __ __ __
Memory loss or memory impairment
No
Yes
__ __ __ __
Migraine headaches
No
Yes
__ __ __ __
Stroke
FT
Stomach, duodenal, or peptic ulcer
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
No
Yes
__ __ __ __
Degenerative joint disease/osteoarthritis
No
Yes
__ __ __ __
Lupus
No
Yes
__ __ __ __
Multiple sclerosis
No
Yes
__ __ __ __
Chronic fatigue syndrome
No
Yes
__ __ __ __
Crohn’s disease
No
Yes
__ __ __ __
Sleep apnea
No
Yes
__ __ __ __
Anemia
No
Yes
__ __ __ __
Infertility
No
Yes
__ __ __ __
Parkinson’s disease
No
Yes
__ __ __ __
Alzheimer’s disease
No
Yes
__ __ __ __
Sexual dysfunction
No
Yes
__ __ __ __
Other (please specify)
No
Yes
__ __ __ __
Traumatic brain injury (Do not include injuries that
resulted in only a concussion)
Neuropathy caused reduced sensation in the
hands or feet
Fibromyalgia
D
Rheumatoid arthritis
A
Seizures
Mark here if you
were ever
hospitalized for the
condition
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26. During the last 12 months, have you had persistent or recurring problems with any of the following? Sea Bee
Rash or skin ulcer
No
Yes
Night sweats
No
Yes
Sore throat
No
Yes
Unusual muscle pain
No
Yes
Frequent bladder infections
No
Yes
Unusual fatigue
No
Yes
Cough
No
Yes
Forgetfulness
No
Yes
Fever
No
Yes
Confusion
No
Yes
Sudden Unexplained hair loss
No
Yes
Trouble Sleeping
No
Yes
FT
27. 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
A
28. 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
29. 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
D
30. Over the past 12 months, approximately how many days were you hospitalized because of illness or injury?
(Excluding lost time for pregnancy and childbirth)
__ __ __ __ days
31. Over the past 12 months, 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
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FT
32. During the last 4 weeks, how much have you been bothered by any of the following problems? PHQ
Bothered a
Not
little
bothered
a. Stomach pain
b. Back pain
c. Pain in your arms, legs, or joints (knees, hips, etc.)
d. Pain or problems during sexual intercourse
e. Headaches
f. Chest pain
g. Dizziness
h. Fainting spells
i. Feeling your heart pound or race
j. Shortness of breath
k. Constipation, loose bowels, or diarrhea
l. Nausea, gas or indigestion
m. Ringing in the ears
n. Difficulty with balance
o. Little to no sexual desire
o. Women only: menstrual cramps or other problems with your periods
PHQ
33. 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
Bothered a
lot
More than half
the days
Nearly every
day
c. Trouble falling or staying asleep, or sleeping too much
e. Poor appetite or overeating
A
d. Feeling tired or having little energy
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
D
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
34. a. In the last 4 weeks, have you had an anxiety attack – suddenly feeling fear or panic? PHQ
No
Yes
No
Yes
No
No
Yes
Yes
If you marked NO, please skip to question XX
b. Has this every happened to you before?
c. Do some of these attacks come suddenly out of the blue – that is, in situations where you
don’t expect to be nervous or uncomfortable?
d. Do these attacks bother you a lot, or are you worried about having another attack?
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35. Think about your last bad anxiety attack?
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PHQ
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 smoke?
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, 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 snake?
k. Were you afraid you were dying?
No
Yes
No
Yes
36. Over the last 4 weeks, how often have you been bothered by any of the following problems?
PHQ
Several
days
More than half
the days
Nearly every
day
FT
Not at all
A
a. Feeling nervous, anxious or on edge, or worrying about a lot
of different things
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
37. Over the last 2 weeks, how often have you been bothered by the following problems?
a. Feeling nervous, anxious or on edge
D
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
GAD 7
Not at all
Several
days
More than half
the days
Nearly every
day
38. On an average day, how many 8-12 oz beverages containing caffeine do you drink?
None
1-2 per day
3-5 per day
6-10 per day
11 or more per day
RAP
PHQ
39. 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?
No
Yes
No
Yes
9
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
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?
No
Yes
40. FOR WOMEN ONLY:
a.
Comment [JLW6]: Web only questions for
women only.
b.
How old were you when your menstrual periods began?
○ 10
○ 11
○ 12
○ 13
○ 9 or less
Have you ever been pregnant? ○ No ‐ skip to question 42h
c.
Are you currently pregnant?
d.
How many births (live born children or stillbirths) have you had? __
e.
Have you given birth within the last 3 years?
f.
How old were you when you first gave birth? __ years old
g.
How many months in total did you breastfeed (total for all children)?
○ 6‐11 months
○ Less than 3 months
○ 3‐5 months
○ 12‐17 months
○ No
○ 14
○ 15
○ 16
○ 17 or more
○ Yes → How many mes? __
○ Yes
○ No
(If 0, skip to question X)
○ Yes
○ 18 or more months
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
i.
How many years in total have you used birth control pills (exclude time periods when you temporarily stopped)?
○ Less than 1 year
○ 1‐2
○ 3‐4
○ 5‐9
○ 10‐19
○ 20 or more
FT
h.
41. Indicate the degree to which each statement describes your feelings or behavior:
A
None or
almost none
of the time
A little
of the
time
DAR5
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
D
42. 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
10
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
43. 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.
No, or less
than once
per week
1-2
3-5
6-14
15+
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)
FT
44. 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
45. Over the past month, how many hours of sleep did you get in an average 24-hour period? Persian Gulf War Survey
__ __ hours
46. Pease rate your sleep pattern for the past 2 weeks. Insomnia Severity Index
Mild
Moderate
Severe
Very Severe
A
None
a. Difficulty falling asleep
b. Difficulty staying asleep
c. Problem waking up too early
47. How SATISFIED/dissatisfied are you with your current sleep pattern? Insomnia Severity Index
Very dissatisfied
Very satisfied
0
1
2
3
4
D
48. 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
Not at all interfering
A little
Somewhat
Much
Very much interfering
49. 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
50. How WORRIED/distressed are you about your current sleep problem? Insomnia Severity Index
Somewhat
Much
Very much
Not at all
A little
11
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
51. 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
52. Do you consider yourself to be:
Heterosexual or straight
Best Practices
Gay or lesbian
Bisexual
Prefer not to answer
53. 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
Not sure
Mostly attracted to females
Only attracted to males
Prefer not to answer
Equally attracted to females and males
Best Practices
FT
54. In the past 3 years, who have you had sex with?
Men only
Best Practices
Women only
Both men and women
I have not had sex
Prefer not to answer
55. 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.)
A
# of days
per week
you exercise
__ days
AND
On those days,
how many
minutes per day
on average do you
exercise
__ __ __ minutes
- None
- Cannot
physically do
OR
__ days
AND
__ __ __ minutes
OR
__ days
AND
__ __ __ minutes
OR
D
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. MODERATE or LIGHT exercise or work that causes
light sweating or slight increases in breathing or heart
rate? (such as walking, cleaning, slow jogging)
NHIS & HEAR
12
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
PCL‐C
56. In the past month have you experienced…?
Not at all
A little bit
Moderately
Quite a bit
Extremely
A
FT
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
57. On a typical day, how much time do you spend sitting and watching TV or videos or using a computer? NHANES
__ __ hours per day
58. 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)
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
________________
D
No
a. Acupuncture
b. Chiropractic
care
c. Spiritual
healing
d. Meditation
Yes
________________
________________
________________
59. 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
13
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
60. 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
FT
61. Please indicate how you feel about each statement.
Very
Strongly
Strongly
MSPSS
Disagree
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
D
A
62. 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
14
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
63. 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
64. In the last 12 months, did you seek care for any of the following?
b. Anxiety
c.
Depression
d. Stress
e. Anger
f.
Substance use
g. Relationship/family issues
Yes
Are you or did you
take medication for
this?
__ __ __
ס
FT
No
a. Posttraumatic stress disorder (PTSD) or
posttraumatic stress (PTS) symptoms
Number of therapy*
sessions attended. If
None, write 0
__ __ __
ס
__ __ __
ס
__ __ __
ס
__ __ __
ס
__ __ __
ס
A
__ __ __
ס
*Therapy sessions are individual or group meetings to treat symptoms without or in addition to medication.
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
65. In the past year, did you drink any type of alcoholic beverage?
No
Yes
D
If you marked NO, skip to question xx
66. In the past year, on those days that you drank alcoholic beverages, on average, how many drinks did you have?
NHIS
__ __ drinks
67. Last week, how many drinks of alcoholic beverages did you have? (If NONE, please enter 0) NHIS
__ __
__ __
__ __
__ __
__ __
__ __
__ __
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
15
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
68. 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
69. FOR MEN ONLY:
In the past year, how often did you typically have 5 or more drinks of alcoholic beverages within a 2-hour period?
NIAAA Taskforce
Never
Monthly or less
2-4 times a month
>4 times a month
70. FOR WOMEN ONLY:
In the past year, how often did you typically have 4 or more drinks of alcoholic beverages within a 2-hour period?
NIAAA Taskforce
Never
Monthly or less
2-4 times a month
>4 times a month
71. In the last 12 months, have any of the following happened to you more than once? PHQ
No
Yes
No
Yes
FT
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
a.
b.
c.
d.
A
72. Have you ever felt any of the following? CAGE
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
D
73. 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)
74. In your lifetime, have you smoked at least 100 cigarettes (5 packs)? Sea Bee
No
Yes
Yes
If you marked NO, skip to question XX
Questions xx-xx refer to smoking CIGARETTES and not electronic cigarettes or vaping
75. At what age did you start smoking? Persian Gulf War Survey
__ __ years old
16
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
76. How many years have or did you smoke an average of at least 3 cigarettes per day (or one pack per week)?
__ __ years
77. Do you CURRENTLY smoke cigarettes?
No, not at all
Yes, every day
Yes, some days
78. 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
79. Have you ever tried to quit smoking? RAP
Yes, and succeeded
Yes, but not successfully
RAP
1 to 2 packs per day
More than 2 packs per day
No
80. Do you CURRENTLY use electronic cigarettes or vape products?
No, not at all
Yes, every day
Yes, some days
Comment [JLW7]: Web only
81. 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 [JLW8]: Web only
PCL‐5
FT
82. In the past month have you experienced…?
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)
A
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
D
e. Trouble experiencing positive feelings (for example,
being unable to feel happiness or having loving feelings
for people close to you)
17
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
83. Have you ever had any of the following life events happened to you? Persian Gulf War Survey
No
If YES, list
most recent year
__
__
__
__
__
__
__
Comment [JLW9]: Web only will see additional
questions
Comment [JLW10]: Web only will see
additional questions
__
__
__
__
__
__
__
FT
a. You moved or changed residence more than once
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)
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. Hazing/initiation rituals
i. Experienced harassment (other than sexual harassment)
j. Experienced discrimination
k. Suffered a violent assault
l. Had a family member or loved one who became severely ill
m. Had a family member or loved one who died
n. Suffered a disabling illness or injury
o. Experienced infidelity or unfaithfulness in a committed relationship
Yes
84. 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
b. Most recent experience ‐ YYYY
D
A
85. 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?
18
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. 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.
Have you suffered a forced sexual relation or sexual assault?
Once with one person
Once with multiple people
More than once with the same person
More than once with multiple people
Not sure
No
No
No
No
No
Comment [JLW11]: 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 biggest effect on you:
No
No
No
Yes
Yes
Yes
No
Yes
No
No
Yes
Yes
FT
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)
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
A
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?
D
What was the gender(s) of the offender(s)?
Male only
Female only
Both male and female
Not sure
19
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. 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.
Have you suffered sexual harassment?
Once with one person
Once with multiple people
More than once with the same person
More than once with multiple people
Not sure
No
No
No
No
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, the one sexual harassment
incident that had the biggest effect 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
No
Yes
No
No
Yes
Yes
FT
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*?
No
A
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?
What was the gender(s) of the offender(s)?
Male only
Female only
Both male and female
Not sure
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
D
No
No
No
No
No
20
Comment [JLW12]: 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
86. Have you ever 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
No
Yes, 1
time
Yes, more than 1 time
If YES, list most
recent year of
exposure
__
__
__
__
__
FT
It would be helpful for this study to know about the background experiences that may have happened to some
JVQ
people.
87. a. Not including spanking on your bottom, before the age of 18, how often did a grown‐up in your life hit, beat, kick,
or physically hurt you in any way?
Never
Once
More than once
Prefer not to answer
b. Not including spanking on your bottom, before the age of 18, how often did a grown‐up ever touch your private parts
when they shouldn’t have or make you touch their private parts? Or did a grown‐up force you to have sex?
Never
Once
More than once
Prefer not to answer
A
c. Before the age of 18, how often did did you get scared or feel really bad because a grown‐up in your life 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
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. Not including spanking on your bottom, before the age of 18, were you neglected?
Never
Once
More than once
Prefer not to answer
21
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
88. 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
No
Daily
Weekly
Monthly
Less than once
per month
For how many months
were you exposed
__ __
__ __
__ __
__ __
__ __
__ __
__ __
FT
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
89. Are you currently serving in the US military?
Yes, Active duty
Yes, Reserve or National Guard
__ __
No
A
90. a. Since 2010 did you retire, separate or leave the service for any reason?
Yes
Noskip to question xx
b. What was your date of separation or retirement from the military?
M M/ Y Y
D
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)
91. 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
Quite a
bit
Extremely
22
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
92. 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
93. 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
94. 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)
FT
95. 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
96. Since 2001, how often have you experienced the following during deployment?
List most
recent year
of exposure
2 0___
2 0___
2 0___
2 0___
2 0___
Never 1 time
D
A
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
2 0___
2 0___
2 0___
2 0___
2 0___
2 0___
2 0___
2 0___
97. Based on your most recent duty assignment, please indicate how much you agree or disagree for each item.
Neither
Strongly
Strongly
DRRI
Disagree agree or
Agree
disagree
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
23
Comment [JLW13]: Web only. Everyone except
those that separated MORE than 3 years ago would
answer.
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
98. 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 [JLW14]: 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
Dissatisfied
Very
dissatisfied
FT
99. 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
Comment [JLW15]: Web only. Only those that
indicate that they are currently married would see
this question.
A
The questions below are about your past and most recent head injuries.
100.
Have you ever 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?
If YES to any item in question xx above, how many total lifetime injuries have occurred?
Prior to joining the service
___ ___ injuries
___ ___ injuries
During the service
After leaving the service
___ ___ injuries
D
101.
If you answered YES to any item in question xx above, please describe the injury events starting
with the most recent one and then the second most recent one.
102.
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)
__ __ / __ __
24
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
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
FT
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
A
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?
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
D
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
25
OMB CONTROL NUMBER: 0703-0064
OMB EXPIRATION DATE: XX/XX/XXXX
RCS APPROVAL NUMBER: TBD
RCS EXPIRATION DATE: XX/XX/XXXX
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
FT
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
103.
For the second 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/my)
__ __ / __ __
A
c. Were you deployed when the injury happened?
No
Yes
d. What causes the injury? (Please choose the single best answer)
Military training
Blast/explosion
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
D
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
26
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
FT
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
A
n. When this injury happened, were any parts of your body 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
R
p. Did you get a medical evaluation/treatment for this injury?
No
Yes
Don‘t know
D
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
104.
How many motor vehicle accident(s)/crash (es) have you ever been in while NOT deployed?
___ ___ accidents/crashes
Comment [JLW16]: Web only.
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
27
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
106.
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
107.
Has someone assisted you with filling out this survey?
No
Yes
FT
105.
Clinic or office visit only
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)
109.
Please provide your email address(es): (Separate multiple email addresses with a space)
110.
What year were you born?
112.
D
111.
A
108.
What are the last four digits of your Social Security Number?
What is today’s date (mm/dd/yyyy)
___ ___ ___ ___
___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
113.
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)
28
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