Inclusion Policy Practice Decoupling Phase II

Enclosure D1: Demographics Form

SURVEY APPROVAL AUTHORITY:

U.S. ARMY RESEARCH INSTITUTE FOR THE BEHAVIORAL AND SOCIAL SCIENCES

SURVEY CONTROL NUMBER: DAPE-ARI-XXXXXX

RCS: MILPC-3

EXPIRES: MM/DD/YYYY

Demographic Information

DO NOT PLACE ANY ADDITIONAL INFORMATION ON THIS PAGE. ONLY ANSWER THE QUESTIONS LISTED BELOW

1. What is your rank? (for example, Private, Private First Class, …) ________

2. What is your age? _______Years

3. To the nearest whole number, how many total years have you served in any of the Armed Forces? ________Years

4. Have you ever been deployed? (circle/mark one)

Yes

No

5. Please indicate whether you are Male or Female: ________

6. What is your highest level of education? (circle/mark one)

GED or High School Diploma

Some College but no degree completed

Associates Degree (for example, AA, AS)

Bachelor’s Degree (for example BA, BS)

Some Graduate Education but no degree completed

Masters (for example, MA, MS)

Doctoral/Professional Degree (for example, Ph.D, MD, DDS, JD)

7. Please circle/select your current relationship status:

Single

Married

Divorced

Legally-Separated

Widowed or Widower

Co-habiting

8. How many children do you provide for? (Provide a numeric answer: 0, 1, 4, etc.)____

9. Are you of Hispanic, Latino, or Spanish origin or ancestry (of any race)?

No, I am not of Hispanic/Latino/Spanish origin

Yes, Chicano, Mexican, Mexican American

Yes, Puerto Rican

Yes, Cuban

Yes, another Hispanic/Latino/Spanish origin (for example, Salvadoran, Dominican, Columbian, Guatemalan, Spaniard, Ecuadorian, etc…)

10. Please indicate your race, circle/select all that apply:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

11. Please circle your branch:

Combat Arms Combat Service Support Combat Support

12. Did you pass your last Army Combat Fitness Test (ACFT) or Army Physical Fitness Test (APFT)? (please circle your response)

Yes, I passed my last ACFT

Yes, I passed my last APFT

No, I did not pass

What was your score on this test? _________

13. Have you ever had to have a tape test? (please circle)

Yes No

14. How long have you served in your current unit?

____ days/months/years (please circle/select one)

15. Which best describes your current active-duty Army career intentions?

Definitely stay in until retirement

Probably stay in until retirement

Definitely stay in beyond present obligation, but not until retirement

Undecided

Probably leave upon completion of current obligation

Definitely leave upon completion of current obligation

16. Have you received any of the following awards in the past year? (circle/select each)

Certificate of Achievement (COA) Yes/no

Army Achievement Medal (AAM) Yes/no

Army Commendation Medal (ARCOM) Yes/no

Meritorious Service Medal (MSM) Yes/no

17. Have you received a promotion in the past six (6) months? (please circle/select one)

Yes No

18. Have you ever been on an Army physical profile? If yes, please indicate how long ago your most recent Army physical profile was by choosing the corresponding response:

Yes, I am currently on an Army physical profile

Yes, I was on an Army physical profile in the past year

Yes, I was on an Army physical profile more than a year ago

No, I have never been on an Army physical profile

19. Please list the weapons on which you are currently qualified and the level you have achieved (i.e. tried but did not qualify, marksman, sharpshooter, or expert):

Weapon: _____________________ Level: ____________

Weapon: _____________________ Level: ____________

Weapon: _____________________ Level: ____________

Weapon: _____________________ Level: ____________

Weapon Options: M4/M4A1 CARBINE; M249 SQUAD AUTOMATIC WEAPON (SAW); M24 SNIPER WEAPON SYSTEM; M240L 7.62 MEDIUM MACHINE GUN; M107 SEMI0AUTOMATIC LONG RANGE SNIPER RIFLE (LRSR); M2A1 .50 CALIBER MACHINE GUN; M240B/L/H 7.62MM MEDIUM MACHINE GUN; M110 7.62MM SEMI-AUTOMATIC SNIPER SYSTEM; MK19 GRENADE MACHINE GUN; M14 7.62; ENHANCED BATTLE RIFLE; XM2010 ENHANCED SNIPER RIFLE

Level Options: Tried but did not qualify, marksman, sharpshooter, expert

20. Have you been punished for any indiscipline issue during the past year (for example, letter of reprimand, article 15, etc.)?

No Yes Uncertain or Prefer not to answer

21. In the last year, have you received a letter of counseling? (for example, for being late for formation, insubordination, or some other violation).

No Yes Uncertain or Prefer not to answer