Millennium Cohort Study Follow-Up Survey
Prospective Studies of US Military Forces and Their Families: The Millennium Cohort Program
MCS Survey_Service Members and Veterans_11.1.2024
Millennium Cohort Study Follow-Up Survey
OMB: 0703-0064
OMB CONTROL NUMBER: 0703-0064 RSC APPROVAL NUMBER: DD-NAVY(AR)2678
OMB EXPIRATION DATE: 02/28/2025 RCS EXPIRATION DATE: 02/28/2025
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 here: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-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: This questionnaire was designed to assess a variety of factors that have motivated and/or discouraged Millennium Cohort participants to stay connected with the study. It will also help capture information that will allow the study staff improve and create new strategies to keep the cohort interested in the study.
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 program improvement. 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. 552a(b)(3).
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.
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 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding 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.
Disclaimer: Answers to this survey are not monitored in real time.
We understand that some of the questions you may encounter are quite personal and sensitive. While every response is incredibly valuable in our study, you do not have to answer all survey questions. You always have the option to skip any questions and leave them blank.
To help protect your privacy, the Millennium Cohort Study has obtained a Certificate of Confidentiality from the National Institutes of Health. We can use the Certificate to legally refuse to disclose information that may identify you in any federal, state, or local civil, criminal administrative, legislative, or other proceedings (for example, if there was a court subpoena).
SLEEP QUALITY
We would like to begin by asking you some questions about your sleeping pattern. Even if you are deployed, underway, participating in training, or have a newborn disturbing your sleep, please answer the following questions about your current sleep pattern.
Over the past month, how many hours of sleep did you get in an average 24-hour period?
During the past month, how often have you taken medicine (prescribed or "over the counter") to help you sleep?
O Not at all during past month
O Less than once a week
O Once or twice a week
O Three or more times a week
Please rate your sleep pattern for the past 2 weeks.
-
None
Mild
Moderate
Severe
Very severe
Difficulty falling asleep
O
O
O
O
O
Difficulty staying asleep
O
O
O
O
O
Problem waking up too early
O
O
O
O
O
Snoring
O
O
O
O
O
How satisfied/dissatisfied are you with your current sleep pattern?
O Very satisfied
O Satisfied
O Moderately satisfied
O Dissatisfied
O Very dissatisfied
To what extent do you consider your sleep pattern to interfere with your daily functioning (daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.) currently?
O Not at all interfering
O A little
O Somewhat
O Much
O Very much interfering
How noticeable to others do you think your sleep pattern is in terms of impairing the quality of your life?
O Not at all noticeable
O A little
O Somewhat
O Much
O Very much noticeable
How worried/distressed are you about your current sleep pattern?
O Not at all worried
O A little
O Somewhat
O Much
O Very much worried
PHYSICAL HEALTH
These next questions are about your physical health, how you feel, and how well you are able to do your daily activities.
Over the past 3 years, approximately how many days were you hospitalized because of illness or injury? Exclude hospitalization for pregnancy and childbirth.
O None
O 1 day
O 2-5 days
O 6-10 days
O 11-15 days
O 16-20 days
O 21-60 days
O > 60 days
Over the past 3 years, approximately how many days were you unable to work or perform your usual activities because of illness or injury? Exclude lost time for pregnancy and childbirth.
O None
O 1 day
O 2-5 days
O 6-10 days
O 11-15 days
O 16-20 days
O 21-60 days
O > 60 days
In the last 3 years, have you had persistent or recurring problems with any of the following?
-
No
Yes
Unusual muscle pains
O
O
Unusual fatigue
O
O
Forgetfulness
O
O
Confusion
O
O
Frequent bladder infections
O
O
Shortness of breath
O
O
Cough
O
O
Severe headache
O
O
During the last 4 weeks, how much have you been bothered by any of the following problems?
-
Not bothered
Bothered a little
Bothered a lot
Stomach pain
O
O
O
Back pain
O
O
O
Pain in your arms, legs, or joints (knees, hips, etc.)
O
O
O
Pain or problems during sexual intercourse
O
O
O
Headaches
O
O
O
Chest pain
O
O
O
Dizziness
O
O
O
Fainting spells
O
O
O
Feeling your heart pound or race
O
O
O
Shortness of breath
O
O
O
Constipation, loose bowels, or diarrhea
O
O
O
Nausea, gas, or indigestion
O
O
O
Women only: Menstrual cramps or other problems with your periods
O
O
O
On a typical day, how much time do you spend sitting? (e.g., at work, commuting, watching TV, playing video games, or using a computer)
hours
per day
-
How
tall are you? feet inches
What is your current weight? pounds
In a typical week, how much time do you spend participating in...
-
# of days per week you exercise
On those days, how many minutes per day on average do you exercise?
STRENGTH TRAINING or work that strengthens your muscles? (such as lifting/pushing/pulling weights)
DaysAND
minutesOR
O none
O cannot physically do
VIGOROUS exercise or work that causes heavy sweating or large increase in breathing or heart rate? (such as running, active sports, marking, biking)
DaysAND
minutesOR
O none
O cannot physically do
MODERATE or LIGHT exercise or work that causes light sweating or slight increases in breathing or heart rate? (such as walking, cleaning, slow jogging)
DaysAND
minutesOR
O none
O cannot physically do
Has your doctor or other health professional ever told you that you have COVID-19 (Coronavirus disease 2019) or have you ever tested positive for SARS-CoV-2 (including at home testing, testing sites, and healthcare settings)?
O No
O Yes, once (or multiple times within a 14-day period)
O Yes, more than once where you were tested at least 14 days apart
If YES, what was the month/year of your first diagnosis/positive test?
month year
Since the beginning of the COVID-19 pandemic, have you ever:
Become
seriously ill with COVID-19? O No O Yes
If YES, what was the month/year of when illness began? month year
Been
hospitalized with COVID-19? O No O Yes
If
YES,
what was the month/year of your first hospitalization? month
year
Recovered from COVID-19? O No O Yes
If YES, what was the month/year of your recovery (no longer experiencing symptoms)?
month
year
Experienced longer term health issues after you recovered from COVID-19? O No O Yes
Please indicate how many of the initial COVID-19 series and booster vaccinations you have received:
-
None
Some
Entire
Initial series
O
O
O
Booster or updated yearly vaccine
O
O
O
What was the month/year of your first dose of vaccination?
month year
In the last 12 months, how long did you take prescription narcotics for pain relief, such as Codeine, OxyContin, Percocet, Vicodin?
O Never
O Less than 1 week
O 1-2 weeks
O 3-4 weeks
O More than 4 weeks
In the last 3 years, has your doctor or other health professional told you that you have any of the following conditions?
-
No
Yes
If YES, in what year were you first diagnosed?
Hypertension (high blood pressure)
O
O
High cholesterol requiring medication
O
O
Coronary heart disease
O
O
Heart attack
O
O
Stroke
O
O
Emphysema/COPD (chronic obstructive pulmonary disease)
O
O
Chronic bronchitis
O
O
Asthma
O
O
Depression
O
O
Posttraumatic stress disorder
O
O
Diabetes or sugar diabetes
O
O
Significant vision loss even with glasses or contact lenses
O
O
Significant hearing loss
O
O
Tinnitus/ringing of the ears
O
O
Migraine headaches
O
O
Degenerative joint disease (osteoarthritis)
O
O
Lupus
O
O
Multiple sclerosis
O
O
Ulcerative colitis
O
O
Crohn’s disease
O
O
Sleep apnea
O
O
Infertility
O
O
Parkinson’s disease
O
O
Basal cell (BCC) or squamous cell (SCC) skin cancer
O
O
Other cancer, excluding BCC or SCC (please specify)
O
O
Sexually transmitted infections (HPV, Chlamydia, Gonorrhea, Syphilis, etc.)
O
O
Any dementia (e.g., mild cognitive impairment, Alzheimer’s Disease, Frontotemporal Dementia, Lewy Body Dementia, etc.)
O
O
Chronic Traumatic Encephalopathy (CTE)
O
O
Autoimmune hypothyroidism (i.e., Hashimoto’s disease)
O
O
Autoimmune hyperthyroidism (i.e., Graves’ disease)
O
O
Traumatic brain injury (not including injuries that resulted in only a concussion)
O
O
Concussion
O
O
Women: Gestational diabetes (diabetes during pregnancy)
O
O
Women: Preeclampsia/eclampsia
O
O
Women: Pelvic inflammatory disease (PID)
O
O
Women: Polycystic ovarian syndrome (PCOS)
O
O
Women: Uterine fibroids
O
O
Women: Post-partum depression
O
O
Women: Post-partum anxiety
O
O
WELL-BEING
These next questions are about how you feel mentally, or physically and how things have been going over the past couple of weeks. Some of these questions will seem slightly repetitive, but we assure you that each has a specific purpose.
In general, would you say your health is:
O Excellent
O Very good
O Good
O Fair
O Poor
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 limited at all
Yes, limited a little
Yes, limited a lot
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
O
O
O
Climbing several flights of stairs
O
O
O
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, 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
Accomplished less than you would like
O
O
O
O
O
Were limited in the kind of work or other activities
O
O
O
O
O
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)?
O None of the time
O A little of the time
O Some of the time
O Most of the time
O All of the time
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
-
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
Accomplished less than you would like
O
O
O
O
O
Didn’t do work or other activities as carefully as usual
O
O
O
O
O
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
O Not at all
O A little bit
O Moderately
O Quite a bit
O Extremely
During the past 4 weeks, how much bodily pain have you had?
O None
O Very mild
O Mild
O Moderate
O Severe
O Very severe
During the past 4 weeks, how much of the time…
|
None of the time |
A little of the time |
Some of the time |
A good bit of the time |
Most of the time |
All of the time |
Have you felt calm and peaceful? |
O |
O |
O |
O |
O |
O |
Do you have a lot of energy? |
O |
O |
O |
O |
O |
O |
Have you felt downhearted and blue? |
O |
O |
O |
O |
O |
O |
About how many times each week do you eat from a fast-food restaurant (such as hamburgers, tacos, or pizza)?
O None
O Once a week
O 2-3 times/week
O 4-7 times/week
O 8-14 times/week
O 15 or more times/week
Do you often feel that you can't control what or how much you eat?
O No
O Yes
Do you often eat, within any 2 hour period, what most people would regard as an usually large amount of food?
O No
O Yes
If you marked YES to either of the above, how often has this been, on average, in the LAST 3 MONTHS?
O Less than once a week
O At least once a week
O At least twice a week
O More than twice a week
Below is a list of problems that people sometimes have in response to a very stressful experience. Please indicate how much you have been bothered by each problem in the past month.
-
Not at all
A little bit
Moderately
Quite a bit
Extremely
Repeated, disturbing, and unwanted memories of the stressful experience?
O
O
O
O
O
Repeated, disturbing dreams of the stressful experience?
O
O
O
O
O
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
O
O
O
O
O
Feeling very upset when something reminded you of the stressful experience?
O
O
O
O
O
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
O
O
O
O
O
Avoiding memories, thoughts, or feelings related to the stressful experience?
O
O
O
O
O
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
O
O
O
O
O
Trouble remembering important parts of the stressful experience?
O
O
O
O
O
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)?
O
O
O
O
O
Blaming yourself or someone else for the stressful experience or what happened after it?
O
O
O
O
O
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
O
O
O
O
O
Loss of interest in activities that you used to enjoy?
O
O
O
O
O
Feeling distant or cut off other people?
O
O
O
O
O
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
O
O
O
O
O
Irritable behavior, angry outbursts, or acting aggressively?
O
O
O
O
O
Taking too many risks or doing things that could cause you harm?
O
O
O
O
O
Being “super alert” or watchful or on guard?
O
O
O
O
O
Feeling jumpy or easily startled?
O
O
O
O
O
Having difficulty concentrating?
O
O
O
O
O
Trouble falling or staying asleep?
O
O
O
O
O
Indicate the degree to which each statement describes your feelings or behavior:
-
Not at all
A little
Moderately
A lot
Very much
I often find myself getting angry at people or situations
O
O
O
O
O
When I get angry, I get really mad
O
O
O
O
O
When I get angry, I stay mad
O
O
O
O
O
Over the last 2 weeks, how often have you been bothered by any of the following problems?
-
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
O
O
O
O
Feeling down, depressed, or hopeless
O
O
O
O
Trouble falling or staying asleep, or sleeping too much
O
O
O
O
Feeling tired or having little energy
O
O
O
O
Poor appetite or overeating
O
O
O
O
Feeling bad about yourself- or that you are a failure or have let yourself or your family down
O
O
O
O
Trouble concentrating on things, such as reading the newspaper or watching television
O
O
O
O
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
O
O
O
O
Thoughts that you would be better off dead or of hurting yourself in some way
O
O
O
O
Over the last 2 weeks, how often have you been bothered by any of the following problems?
-
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge
O
O
O
O
Not being able to stop or control worrying
O
O
O
O
Please read each statement and write the number for the answer that best reflects your own views.
-
Disagree
Somewhat disagree
Neutral
Somewhat agree
Agree
I hide my aches and pains from others.
O
O
O
O
O
I manage my own problems without help from anyone.
O
O
O
O
O
The next questions are about thoughts of hurting yourself. We are aware that many of these next questions are quite personal, and we would appreciate your candid response.
If you or someone you know needs help with their emotions or behavioral health, please contact one of these numbers:
Emergency: 911
988 Suicide & Crisis Lifeline: 988
The Veterans Crisis Line: 1‐800‐273‐TALK (8255) and Press 1 or Text: 838255
Chat Online: http://www.veteranscrisisline.net/get‐help/chat
Military One Source: 1‐800‐342‐9647
Chat Online: https://livechat.militaryonesourceconnect.org/chat/
The Defense Center of Excellence (DCoE): 1‐866‐966‐1020
Wounded Soldier and Family Hotline: 1‐800‐984‐8523
CONUS DSN: 421‐3700
OCONUS DSN: 312‐421‐3700
Please choose the statement or phrase that best applies to you. Select ONE ANSWER for each question.
Have you ever thought about or attempted to kill yourself?
O Never
O It was just a brief passing thought
O I have had a plan at least once to kill myself but did not try to do it
O I have had a plan at least once to kill myself and really wanted to die
O I have attempted to kill myself, but did not want to die
O I have attempted to kill myself, and really hoped to die
How often have you thought about killing yourself in the past year?
O Never
O Rarely (1 time)
O Sometimes (2 times)
O Often (3-4 times)
O Very Often (5 or more times)
Have you ever told someone that you were going to commit suicide, or that you might do it?
O No
O Yes, at one time, but did not really want to die
O Yes, at one time, and really wanted to do it
O Yes, more than once, but did not want to do it
O Yes, more than once, and really wanted to do it
How likely is it that you will attempt suicide someday?
O Never
O No chance at all
O Rather Unlikely
O Unlikely
O Likely
O Rather Likely
O Very Likely
Have you ever intentionally hurt yourself (e.g., cut or hit yourself) without any intention of killing yourself?
O No
O Yes
Please circle or mark one number per line to indicate your response as it applies to the past 7 days.
-
Not at all
A little bit
Somewhat
Quite a bit
Very much
I have a reason for living
O
O
O
O
O
I feel a sense of purpose in my life
O
O
O
O
O
The following statements are intended to assess your beliefs about your current problems. Please read each statement carefully and circle the number that best describes how you feel right now.
-
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
It is unbearable when I get this upset.
O
O
O
O
O
I can’t imagine anyone being able to withstand this kind of pain
O
O
O
O
O
I don’t deserve to live another moment
O
O
O
O
O
The next questions are about how you feel about different aspects of your life. For each one, indicate how often you feel that way.
-
Hardly ever
Some of the time
Often
How often do you feel that you lack companionship?
O
O
O
How often do you feel left out?
O
O
O
How often do you feel isolated from others?
O
O
O
Over the course of your lifetime has a close friend or family member died by suicide?
O No
O Yes
If yes, were any of these individuals who died by suicide a service member or veteran?
O No
O Yes
In the last 2 weeks…
-
Never true
Rarely true
Occasionally true
Often true
Very often true
Always true
I was able to let negative feelings come and go without getting caught up in them
O
O
O
O
O
O
In tough situations, I was able to notice my thoughts and feelings without getting overwhelmed by them
O
O
O
O
O
O
SUPPORT AND COPING
Now we would like to ask you some questions about your support system and how you cope with life's changes.
Please indicate how you feel about each statement.
-
Very strongly disagree
Strongly disagree
Mildly disagree
Neutral
Mildly agree
Strongly agree
Very strongly agree
There is a special person who is around when I am in need.
O
O
O
O
O
O
O
I get the emotional help and support I need from my family.
O
O
O
O
O
O
O
I have a special person who is a real source of comfort to me.
O
O
O
O
O
O
O
I have friends with whom I can share my joys and sorrows.
O
O
O
O
O
O
O
My family is willing to help me make decisions.
O
O
O
O
O
O
O
I can talk about my problems with my friends.
O
O
O
O
O
O
O
In the past 3 years, about how often have you participated in or volunteered for any of the following community groups or organizations?
-
Never
Once or twice
Once a month
Once a week
More than once a week
Veteran Service Organizations (e.g., Veterans of Foreign Wars, American Legions, Disabled American Veterans, Wounded Warrior Project, Iraq and Afghanistan Veterans of America)
O
O
O
O
O
Other veteran-oriented groups (e.g., virtual or social media groups and/or in-person social or activity groups)
O
O
O
O
O
Community service or volunteer organizations/events (e.g., local shelter, Kiwanis club)
O
O
O
O
O
Other social groups (e.g., churches or other religious groups, sports teams, etc.)
O
O
O
O
O
During the last 4 weeks, how much have you been bothered by any of the following problems?
-
Not bothered
Bothered a little
Bothered a lot
The stress of taking care of children, parents, or other family members
O
O
O
Having no one to turn to when you have a problem
O
O
O
Difficulties with husband/wife, partner/lover, or boyfriend/girlfriend
O
O
O
Little or no sexual desire or pleasure during sex
O
O
O
In the past 12 months, how much have you experienced difficulty coping with grief over the death of someone close?
O Not at all
O A little bit
O Moderately
O Quite a bit
O Extreme
Military service can entail doing or witnessing acts that may affect one’s emotional well-being, relationships, and later quality of life. When considering your own feelings, beliefs, and behaviors related to things that you did/saw in the military, please indicate how much you personally agree or disagree with each statement.
-
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I am ashamed of myself because of things that I did/saw during my military service.
O
O
O
O
O
I am troubled because I violated my morals by failing to do something that I should have done during my military service.
O
O
O
O
O
I feel guilt about things that happened during my military service that cannot be excused.
O
O
O
O
O
The moral failures that I witnessed during my military service have left a bad taste in my mouth.
O
O
O
O
O
Things I saw/did in the military have caused me at times to lose faith in the basic goodness of humanity.
O
O
O
O
O
MILITARY SERVICE
The following questions are about your military service. Even if you left military service, please try to answer all of the questions that apply to you.
Since 2001, did you retire, separate, or leave the service for any reason?
O No
O Yes
What
was the year of your most recent
retirement/separation?
Year
How much did each of the following reasons affect your decision to leave the military?
-
Not at all
A little bit
Moderately
Quite a bit
Extremely
Desire to continue your education, start a new career, or change in personal goals
O
O
O
O
O
Disability or other medical reasons
O
O
O
O
O
Difficulty meeting weight standards and/or fitness standards
O
O
O
O
O
Incompatibility with the military
O
O
O
O
O
Legal problems or problems meeting a military obligation
O
O
O
O
O
Dissatisfaction with deployments and/or frequent moves
O
O
O
O
O
Military service created hardship for family
O
O
O
O
O
Dissatisfaction with job or leadership/supervision
O
O
O
O
O
Dissatisfaction with promotion, pay, or other benefits
O
O
O
O
O
Fulfilled term of service or was retirement eligible
O
O
O
O
O
Since your most recent separation date, have you rejoined any branch of the military for any reason? (Including the Reserves or National Guard).
O No
O Yes
In the last 3 years, how often have you experienced the following during deployment? If you have
NOT deployed in the last 3 years, please choose NO.
-
No
1 time
More than 1 time
List most recent year of exposure
Feeling that you were in great danger of being killed
O
O
O
Being attacked or ambushed
O
O
O
Receiving small arms fire
O
O
O
Clearing/searching homes or buildings
O
O
O
Having an improvised explosive device (IED) or booby trap explode near you
O
O
O
Being wounded or injured
O
O
O
Seeing dead bodies or human remains
O
O
O
Having a member of your unit be seriously injured or killed
O
O
O
Being directly responsible for the death of an enemy combatant
O
O
O
Being directly responsible for the death of a non-combatant
O
O
O
Being exposed to smoke from burning trash and/or feces
O
O
O
Based on your most recent/last duty assignment, please indicate how much you agree or disagree for each item.
-
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I feel a sense of camaraderie between myself and others in my unit
O
O
O
O
O
I was impressed by the quality of leadership in my unit
O
O
O
O
O
I was supported by the military
O
O
O
O
O
All participants: How satisfied are/were you with each of the following aspects of your military service?
-
N/A
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
Pay and housing allowance
O
O
O
O
O
O
Medical/health care for you and your family
O
O
O
O
O
O
Pace of promotions/chance for advancement
O
O
O
O
O
O
Frequencies of deployments/unaccompanied tours
O
O
O
O
O
O
Impact on spouse's employment and career opportunities
O
O
O
O
O
O
Time with family
O
O
O
O
O
O
All participants: What is your overall feeling about your military service?
O Negative
O Somewhat negative
O Neither negative nor positive
O Somewhat positive
O Positive
Are you currently an Active Duty service member or on title 10 Active Duty orders?
O No
O Yes
Where do you currently live?
O On-base
O Off-base
O Aboard a ship
The next questions are about safety and firearms. Some people keep guns for recreational purposes such as hunting or sport shooting. People also keep guns in the home for protection. Please include firearms such as pistols, revolvers, shotguns, and rifles, but not BB guns or guns that cannot fire. Include those kept in a garage, outdoor storage area, or motor vehicle.
(Active-Duty version) Do you currently have a personal firearm(s) (e.g., not a military-issued firearm(s)) at your on-base residence?
(Veteran version) Are any firearms now kept in or around your home?
O No
O Yes
O Don’t know/not sure
O Prefer not to answer
(Active Duty version) Are any of these firearm(s) at your on-base residence now loaded?
(Veteran version) Are any of these firearms now loaded?
O No
O Yes
O Don’t know/not sure
O Prefer not to answer
(Active Duty version) Are any of these firearm(s) at your on-base residence now unlocked?
(Veteran version) Are any of these loaded firearms unlocked?
O No
O Yes
O Don’t know/not sure
O Prefer not to answer
How much do you agree or disagree with the following statements?
-
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Firearms should be stored in a firearm safe.
O
O
O
O
O
Firearms should be stored locked and unloaded with ammunition stored separately when they are not in use.
O
O
O
O
O
Having a firearm in the house makes it a safer place to be.
O
O
O
O
O
Anyone who has a firearm(s) should have conversations with their family about firearm safety.
O
O
O
O
O
LIFE EXPERIENCES
The following questions are about harassment, which is behavior that is unwelcome or offensive, whether oral, written (including through electronic devices or communications), or physical, that creates an intimidating, hostile, or offensive environment. Activities or actions undertaken for a proper military or governmental purpose, such as combat survival training, are not considered harassment.
In the last 3 years, how often have you experienced…
|
Not at all |
Rarely |
Monthly |
Daily |
Did you experience this as part of your military duties? |
Discrimination? (i.e., differential or unfair treatment based on your race, color, religion, sex, gender identity national origin, or sexual orientation) |
O |
O |
O |
O |
|
Bullying? (i.e., acts of aggression with the intent of physically or psychologically harming a person) |
O |
O |
O |
O |
|
Hazing? (i.e., acts that physically or psychologically injure or create a risk of injury in order to humiliate or “toughen up" people to fit into a group) |
O |
O |
O |
O |
|
Sexual harassment? (i.e., repeated offensive comments or gestures of a sexual nature that may affect a person’s job, pay, work performance, or career) |
O |
O |
O |
O |
|
We are aware that many of these next questions about your experiences are quite personal, and we would appreciate your candid response. We want to assure you that all of your answers will be kept strictly confidential.
In the past 3 years, have any of the following life events happened to you?
-
No
Yes
If YES, list most recent year
You moved or changed residence more than once
O
O
You changed job, assignment, or career path involuntarily (for example, you lost a job, or you had to take a job you did not like)
O
O
You or your partner had an unplanned pregnancy
O
O
You were divorced or separated
O
O
Suffered major financial problems (such as bankruptcy)
O
O
Suffered forced sexual relations or sexual assault
O
O
Suffered a violent assault
O
O
Had a family member or loved one who became severely ill
O
O
Had a family member or loved one who died
O
O
Suffered a disabling illness or injury
O
O
Experienced infidelity or unfaithfulness in a committed relationship
O
O
In the past 3 years, how many times 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, or attempted to or actually made you have sexual intercourse/oral or anal sex (including penetration with finger/object) without your consent?
O Never
O Once
O Twice
O A few times
O Many times
You indicated that you have experienced unwanted sexual contact or sexual assault. These unwanted experiences may vary in severity and can happen to women and men. Please answer the next questions thinking about any experiences, in the past 3 years, no matter who did it to you or where it happened, even if you or others were drinking or intoxicated. Please include unwanted sexual experience(s) without your consent involving any type of sexual contact, forced sexual relations, or sexual assault.
Your individual answers on this survey are confidential and will not be reported to anyone outside the Millennium Cohort Study team. If you have experienced any of these situations, please consider calling the free National Sexual Assault Hotline at 1-800-656-HOPE (4673) or visiting https://rainn.org/
In the past 3 years, did any of the unwanted sexual experiences occur during your military service, no matter who did it or where it happened?
O No
O Yes
Please answer the next questions thinking about any unwanted sexual experiences, in the last 3 years, no matter who did it to you or where it happened, even if you or others were drinking or intoxicated. Please include unwanted sexual experience(s) without your consent involving any type of sexual contact, forced sexual relations, or sexual assault.
Your individual answers on this survey are confidential and will not be reported to anyone outside the Millennium Cohort Study team.
In the past 3 years, at the time that any of the unwanted sexual experiences occurred, was/were the offender(s)...? (please mark all that apply)
-
No
Yes
Your spouse/significant other?
O
O
Other friend(s), relative(s), acquaintance(s)?
O
O
Someone from work (e.g., co-worker, supervisor)?
O
O
Unknown person (s)?
O
O
ALCOHOL, TOBACCO, & VAPE USE
For the questions below, please refer to the following definitions: Cigarette refers to tobacco cigarettes such as Marlboro, Camel, etc. E-cigarette/vape refers to electronic nicotine vapor products such as JUUL, SMOK, Suorin, Vuse, and blu. Electronic vapor products include e-cigarettes, vapes, vape pens, e-cigars, ehookahs, hookah pens, and mods (do not count marijuana electronic vapor products) Smokeless tobacco refers to chewing tobacco, snuff, dip, snus, or dissolvable tobacco products, such as Copenhagen, Grizzly, Skoal, or Camel Snus |
In the past year, have you used any of the following tobacco/nicotine products?
-
No
Yes
Cigarettes
O
O
Cigars
O
O
Electronic cigarettes or vape products
O
O
Pipes
O
O
Smokeless tobacco (chew, dip, snuff)
O
O
Do you CURRENTLY use electronic cigarettes or vape products?
O No, not at all
O Yes, some days
O Yes, every day
Have you used electronic cigarettes or vape products in the past (more than a year ago)?
O No, not at all
O Yes, some days
O Yes, every day
Are you using (or have you used) e-cigarettes or vaping products …? (Mark all that apply.)
O To quit combustible cigarette smoking
O In places where combustible cigarette smoking is not allowed
O As a replacement for using combustible cigarettes
O Because they are cheaper than combustible cigarettes
O Because they are safer than combustible cigarettes
O Other
In your lifetime, have you smoked at least 100 cigarettes (5 packs)?
O No
O Yes
Do you CURRENTLY smoke cigarettes?
O No, not at all
O Yes, some days
O Yes, every day
When smoking, how many packs per day did you or do you smoke?
O Less than half a pack a day
O Half to one pack per day
O 1 to 2 packs per day
O More than 2 packs per day
Have you ever tried to quit smoking (e-cigarettes or cigarettes)?
O Yes, and succeeded
O Yes, but not successfully
O No
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.
In the past year, how often did you drink any type of alcoholic beverage?
O Never
O Rarely
O Monthly
O Weekly
O Daily
In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage? (If NONE, please enter 0)
days
Last week, how many drinks of alcoholic beverages did you have? (If NONE, please enter 0)
-
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
In the last 12 months, have any of the following happened to you more than once?
-
No
Yes
You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health
O
O
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
O
O
You missed or were late for work, school, or other activities because you were drinking or hung over
O
O
You had a problem getting along with people while you were drinking
O
O
You drove a car after having several drinks or after drinking too much
O
O
FAMILY AND RELATIONSHIPS
-
How
many children do you have? (Please include biological, adopted,
foster, legal guardianship, and stepchildren of all
ages). Child(ren)
Are any of your children aged 17 or younger?
O No
O Yes
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)
In general, how well do you feel you are coping with the day-to-day demands of parenthood/raising children?
O I do not have children
O Very poorly
O Poorly
O Fair
O Somewhat well
O Very well
*Question 86 will be seen by those MCS participants that are/were previously married to a spouse who is/was a participant in the FSC. All other participants will see item 87.
If a participant indicates on question 86 they are divorced or widowed, in subsequent survey cycles they will begin seeing question 87.
What is your current marital status to the individual you were married to in <Month Year> (*month and year are the MCS participant’s previous survey completion dates)?
O Currently married
O Separated
O Divorced
O Widowed
What is your current marital status?
O Single, never married
O Now married
O Separated
O Divorced
O Widowed
(If married ) Has your spouse ever served in the US military? (select all that apply).
O No
O Yes, Reserve or National Guard
O Yes, Active Duty
If Yes, is your spouse currently serving in the US military?
O No
O Yes, Reserve or National Guard
O Yes, Active Duty
Please choose one of the following to describe your current relationship status:
O Not dating
O Dating casually
O In a committed relationship, living separately
O In a committed relationship, living together
Taking things all together, how would you describe your relationship with your significant other?
Very Very
unhappy happy
O O O O O O O
1 2 3 4 5 6 7
I feel that I can trust my partner completely.
O Very strongly disagree
O Strongly disagree
O Mildly disagree
O Neutral
O Mildly agree
O Strongly agree
O Very strongly agree
<<If not currently married or committed relationship >>
Have you been in any type of relationship in the last 12 months (including someone you dated and/or had a sexual relationship with, an ex-spouse, boyfriend, or girlfriend)?
O No
O Yes
Sometimes in close relationships, people do or say things that are hurtful during a disagreement or in a difficult situation. In the next series of questions, please tell us if something like this has occurred in your relationship.
Pop-up message: If you are experiencing physical or emotional abuse from your spouse, please consider calling the toll-free National Domestic Violence Hotline at 1-800-799-SAFE (7233) or visiting http://www.hotline.org/.
Skip/exit button to quickly decline if the abuser is close by or can see the survey.
How often has this happened in the past 12 months?
-
Never
Rarely
Sometimes
Fairly often
Frequently
You screamed or cursed at your partner (Examples: yelled at them, swore at them, etc.)
O
O
O
O
O
Your partner screamed or cursed at you (Examples: yelled at you, swore at you, etc.)
O
O
O
O
O
You insulted or talked down to your partner (Examples: called them names, belittled them, etc. )
O
O
O
O
O
Your partner insulted or talked down to you (Examples: called you names, belittled you, etc.)
O
O
O
O
O
You threatened your partner with harm (Examples: threatened to hit, throw something, or hurt them; intimidated them; punched a wall in front of them, etc.)
O
O
O
O
O
Your partner threatened you with harm (Examples: threatened to hit, throw something, or hurt you, intimidated you; punched a wall in front of you, etc.)
O
O
O
O
O
You physically hurt your partner (Examples: pushed, slapped, grabbed, punched, kicked, etc.)
O
O
O
O
O
Your partner physically hurt you (Examples: pushed, slapped, grabbed, punched, kicked, etc.)
O
O
O
O
O
WOMEN’S SECTION
The women's health section covers topics such as menstruation, birth control, and pregnancy. If these items do not apply to you, please use the skip button at the bottom of this page to skip this section.
We realize that some of the following questions are very sensitive, but it is important to answer them as accurately as you can.
As a reminder, to help protect your privacy, the Millennium Cohort Study has obtained a Certificate of Confidentiality from the National Institutes of Health. We can use the Certificate to legally refuse to disclose information that may identify you in any federal, state, or local civil, criminal administrative, legislative, or other proceedings (for example, if there was a court subpoena).
How many times have you been pregnant? Include live births, stillbirths, miscarriages, and other pregnancies. If you are currently pregnant, be sure to count this pregnancy.
Pregnancy(ies)
How many births (live born children and stillbirths) have you had? (Count each set of twins or multiples as 1).
Birth(s)
Are you currently pregnant?
O No
O Yes
O Not sure
Not including right now, have you been pregnant in the last three years?
O No
O Yes
Not including right now, how many times have you been pregnant in the last three years?
What was the outcome of your most recent pregnancy?
O Single live birth
O Single stillbirth
O Multiple birth
O Miscarriage or spontaneous abortion (including chemical pregnancy)
O Elective or therapeutic abortion
O Tubal or ectopic pregnancy
O Molar pregnancy
How
many babies did you deliver?
How many of these babies were live born?
About how many gestational weeks was your most recent pregnancy when it ended?
Weeks
OR O Do not recall
When did your most recent pregnancy end (regardless of the outcome)? Fill in with as much detail as you can recall.
Month Day
Year
Thinking back to just before your most recent pregnancy, how did you feel about becoming pregnant?
O I wanted to be pregnant later
O I wanted to be pregnant sooner
O I wanted to be pregnant then
O I didn’t want to be pregnant then or at any time in the future
O I wasn’t sure what I wanted
These next questions ask about your behaviors before and during your most recent pregnancy.
-
In the 3 months before your last pregnancy…
During the last 3 months of your last pregnancy…
Did you smoke cigarettes?
O No, not at all
O Yes, some days
O Yes, every day
O No, not at all
O Yes, some days
O Yes, every day
How many alcohol drinks did you have in an average week?
O I didn’t drink then
O Less than 1 drink a week
O 1 to 3 drinks a week
O 4 to 7 drinks a week
O 8 to 13 drinks a week
O 14 drinks or more a week
O I didn’t drink then
O Less than 1 drink a week
O1 to 3 drinks a week
O 4 to 7 drinks a week
O 8 to 13 drinks a week
O 14 drinks or more a week
About how much weight would you say you gained during your most recent pregnancy?
O Less than 20 pounds
O 20 to 35 pounds
O More than 35 pounds
These next questions ask about the live born infant(s) from your most recent pregnancy.
Baby 1 |
Baby 2 |
Baby 3 |
Baby 4 |
What was this baby’s sex at birth? O Male O Female
|
What was this baby’s sex at birth? O Male O Female
|
What was this baby’s sex at birth? O Male O Female
|
What was this baby’s sex at birth? O Male O Female
|
What was this baby’s weight at delivery? ____ grams ____pounds ____ounces O Don’t know
If “Don’t know:” Was this baby’s birth weight less than 5 pounds or was it 5 pounds or more? O < 5 pounds O ≥ 5 pounds
|
What was this baby’s weight at delivery? ____ grams ____pounds ____ounces O Don’t know
If “Don’t know:” Was this baby’s birth weight less than 5 pounds or was it 5 pounds or more? O < 5 pounds O ≥ 5 pounds
|
What was this baby’s weight at delivery? ____ grams ____pounds ____ounces O Don’t know
If “Don’t know:” Was this baby’s birth weight less than 5 pounds or was it 5 pounds or more? O < 5 pounds O ≥ 5 pounds
|
What was this baby’s weight at delivery? ____ grams ____pounds ____ounces O Don’t know
If “Don’t know:” Was this baby’s birth weight less than 5 pounds or was it 5 pounds or more? O < 5 pounds O ≥ 5 pounds
|
Did this baby live for at least 28 days? O No O Yes
|
Did this baby live for at least 28 days? O No O Yes
|
Did this baby live for at least 28 days? O No O Yes
|
Did this baby live for at least 28 days? O No O Yes
|
Have you ever used oral contraceptives (birth control pills)?
O No
O Yes
If yes, how many years in total have you used birth control pills? Exclude time periods when you temporarily stopped.
O Less than on year
O 1-2 years
O 3-4 years
O 5-9 years
O 10 or more years
Age
when last used years
old OR
check if currently taking.
If currently using oral contraceptives:
How many consecutive years have you been using oral contraceptives?
O Less than one year
O 1-2 years
O 3-4 years
O 5-9 years
O 10 or more years
Why are you using oral contraceptives (check all that apply)?
O Birth control
O Acne
O Menstrual cramps or painful periods
O To regulate periods
O To suppress/stop periods
O To treat vaginal bleeding
O Other
Do you currently use any of these other forms of contraception?
O Hormonal IUD (e.g., Mirena)
O Depo Provera injection
O Copper IUD (e.g., ParaGard)
O Vaginal ring (e.g., NuvaRing)
O Implant (e.g., Nexaplon)
O Patch (e.g., Ortho Evra)
O None of the above
How many consecutive years have you been using this current form of contraception?
O Less than one year
O 1-2 years
O 3-4 years
O 5-9 years
O 10 or more years
Have you had a hysterectomy? (This is an operation to take out your uterus or womb)
O No
O Yes
If
YES,
what was your age at surgery? years
How would you describe your current menstrual status?
O Premenopause (before menopause)
O Perimenopause/menopause transition (changes in periods, but have not gone 12 months in a row without a period)
O Postmenopause (after menopause)
If PREMENOPAUSAL, are your periods usually regular?
O No
O Yes
If POSTMENOPAUSAL, was your menopause
O Spontaneous (“natural”)
O Surgical (removal of both ovaries)
O Due to chemotherapy or radiation therapy
O Other
-
What
was your age when you had your
last
period? years
HEALTH CARE
What kind of health coverage or insurance do you currently have? (Mark all that apply)
O No health coverage or insurance
O VA health care (Department of Veterans Affairs/Veterans Health Administration)
O TRICARE or military health insurance plan
O Medicaid
O Medicare
O Other private insurance
Please select the answer that best reflects your own views about seeking mental health care.
-
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
I would prefer to manage psychological problems on my own.
O
O
O
O
O
I do not trust mental health professionals.
O
O
O
O
O
I do not know where to get help for psychological problems.
O
O
O
O
O
Mental health services are not available.
O
O
O
O
O
Mental health care can be helpful for those who need it.
O
O
O
O
O
I would be seen as weak.
O
O
O
O
O
It would be too embarrassing.
O
O
O
O
O
I would prefer to seek help from another source (e.g., Chaplain).
O
O
O
O
O
I am concerned others would think less of me.
O
O
O
O
O
I am concerned it would impact my job.
O
O
O
O
O
In the last 12 months, how many times did you receive ANY mental health services (including therapy sessions, group sessions, counseling)?
O None
O 1-3 times
O 4-5 times
O 6-8 times
O 9-12 times
O 13-20 times
O 20-29 times
O 30 or more times
For the next questions about specific mental health treatments, please do your best to estimate how much therapy and/or any medication you received for each condition. If you received therapy or medication to treat more than one condition, please count that therapy or medication for all conditions listed.
In the last 12 months, have you received therapy or medication for any of the following?
|
Not at all |
Rarely |
Total number of group sessions |
Total number of individual sessions |
Are you taking or did you take medication for this condition |
|
PTSD or PTS symptoms |
O |
O |
|
|
|
|
Depression |
O |
O |
|
|
|
|
Anxiety |
O |
O |
|
|
|
|
Relationship/family issues |
O |
O |
|
|
|
|
Substance abuse |
O |
O |
|
|
|
|
Sleep related problems |
O |
O |
|
|
|
|
DEMOGRAPHICS
What is today's date? (Paper only)
What are the last four digits of your Social Security Number? (Paper only)
What year were you born? (Paper only) _______ year
What is the highest level of education that you have completed?
O Less than high school completion/diploma
O High school degree/GED/or equivalent
O Some college, no degree
O Associate's degree
O Bachelor's degree
O Master's, doctorate, or professional degree
Which of the following best describes your employment status?
O Full-time (greater than or equal to 30 hours per week)
O Part-time (less than 30 hours per week)
O Not employed, looking for work
O Not employed, not looking for work
O Not employed, retired
O Not employed, disabled
O Homemaker
O Other, please specify:
Which best describes the financial condition of you and your family?
O Very comfortable and secure
O Able to make ends meet without much difficulty
O Occasionally have some difficulty making ends meet
O Tough to make ends meet but keeping our heads above water
O In over our heads
These next questions are about the financial status of you and your household.
-
No
Yes
Are you able to pay for all necessary expenses each month, such as mortgage/rent, debt payments, and groceries?
O
O
Does your household have at least 3 months of your typical income set aside in case of an unexpected financial event?
O
O
Does your household have the insurance coverage you and/or your family would need if an unexpected financial event were to occur (for example, disability insurance, property insurance, and/or life insurance)?
O
O
Has your household begun to set aside money for retirement?
O
O
Is your household more than one month behind on your debt payments (for example, mortgage or credit card)?
O
O
Are you currently concerned that you will lose your housing and be unable to find stable alternative housing?
O
O
How many total months were you away from home in the past year for reasons related to your military or civilian work (e.g., work-related travel, deployments, training, temporary duty, TDY/TAD)?
months
At any time in the last 6 years have you found it necessary to sleep in a shelter, on the streets, or in another non-residential setting because of having no other place to stay? (Please only refer to instances during or after military service)
O No
O Yes
If YES, please indicate the dates of your most recent situation:
Month Year OR if it is currently ongoing
These next questions are about the food eaten in your household in the last 12 months and whether you were able to afford the food you need.
-
Never true
Sometimes true
Often true
I worried whether my food would run out before I got money to buy more
O
O
O
The food that I bought just didn’t last, and I didn’t have money to get more
O
O
O
We realize that some of the following questions are very sensitive, but it is important to answer them as accurately as you can. We want to assure you that all of your answers will be kept strictly confidential.
What sex were you assigned at birth, on your original birth certificate?
O Male
O Female
How would you describe your current gender?
O Male
O Female
O Transgender, male to female
O Transgender, female to male
O Prefer not to answer
O Not listed, please specify______________
Do you consider yourself to be:
O Heterosexual or straight
O Gay or Lesbian
O Bisexual
O Prefer not to answer
O Something else, please specify ______________
Who have you EVER had sex with?
O Men only
O Women only
O Both men and women
O I have not had sex
O Prefer not to answer
OCCUPATIONAL/ENVIRONMENTAL EXPOSURES & INJURY
The following questions pertain to your time in military service.
In the military, were you ever employed as a firefighter?
O No
O Yes, I am currently employed as a firefighter in the military
O Yes, but I am not currently employed as a firefighter in the military
How
old were you when you were first
employed as a
firefighter in the military?
About how many total years and/or months were you employed as a firefighter in the military?
years
months
In the military, were you ever exposed to synthetic firefighting foam (aqueous film forming foam) for at least once a week in any job you had?
O No
O Yes
O Don’t know
If
YES to, how old were you when you first
were exposed to
synthetic firefighting foam?
years
About
how long in total
were you exposed to synthetic firefighting foam?
years months
About
how many days per week
were you exposed on average? Days
When you were exposed to synthetic firefighting foam, how often did you wear protective clothing such as masks, gloves, and/or coveralls?
O Never
O Some of the time
O Most of the time
O All of the time
Are you currently exposed to synthetic firefighting foam at least once a week?
O No
O Yes
O Don’t know
Have you ever been exposed to a blast or explosion, such as that from a bomb, improvised explosive device, a controlled demolition, a land mind, a grenade, etc.?
O No
O Yes
When did these blasts/explosions occur? (Check all that apply.)
O Before military service
O During military service
O After military service
Approximately how many blasts or explosions have you been exposed to in your lifetime?
times while deployed
times while not deployed
Considering your history of blast exposure, have you ever been exposed to any blast while…
(Check all that apply.)
O In a vehicle
O Indoors in an enclosed space
O Outdoors in an enclosed space (like an alley) or near a structure (like a building)
O Outdoors in an open field
When
was your most recent
exposure to a blast or explosion? Month
Year
Please indicate below how many times you were exposed to blasts or explosions...
closer than 50 meters away? 50-100 meters away? farther than 100 meters away?
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
Being dazed right after the injury?
O
O
O
Being confused or not thinking clearly right after the injury?
O
O
O
Not remembering the actual injury right after it happened?
O
O
O
Not remembering things that happened right after the injury?
O
O
O
Losing consciousness or being knocked out?
O
O
O
How many total lifetime injuries have occurred?
During the service? After leaving the service?
injuries
injuries
How many head injuries have happened in the past three years?
O One injury
O More than one injury
For the most recent injury that resulted in being dazed, confused, not remembering, etc.:
Was this your most serious injury that resulted in being dazed, confused, not remembering, etc.?
O No
O Yes
When
did it happen? Month Year
Were you deployed when the injury happened?
O No
O Yes
What caused the injury? (Please choose the single best answer)
O Blast/explosion
O Military training
O Fighting with someone
O Bullet/fragment
O Playing sports/recreation activity/PT
O Other
O Motor vehicle crash
O Fall
O Don’t know
Right after the injury, were you dazed?
O No
O Yes
O Don’t know
How long did it last?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
Right after the injury, were you confused or not thinking clearly?
O No
O Yes
O Don’t know
How long did it last?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
Were you unable to remember things that happened right before the injury, the actual injury itself, and/or things that happened right after the injury?
O No
O Yes
O Don’t know
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?
O Less than 1 hour
O 1 hour to 24 hours
O More than 24 hours but less than 7 days
O 7 days or more
O Don’t know
Were you unconscious or knocked out?
O No
O Yes
O Don’t know
How long were you unconscious or knocked out?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
When this injury happened, were any parts of your body injured OTHER THAN your head?
O No
O Yes
O Don’t know
Did this injury disrupt your personal and/or work activities for more than 1 day?
O No
O Yes
O Don’t know
Did you get a medical evaluation/treatment for this injury?
O No
O Yes
O Don’t know
Where did you get evaluated/treated? (Check all that apply)
O In the field by a medic
O Outpatient clinic/doctor’s office
O Emergency room/urgent care center
O Admitted to the hospital as an INPATIENT how many nights? ___
O Don’t know
For the second most recent injury that resulted in being dazed, confused, not remembering, etc.:
Was this your most serious injury that resulted in being dazed, confused, not remembering, etc.?
O No
O Yes
When
did it happen? Month Year
Were you deployed when the injury happened?
O No
O Yes
What caused the injury? (Please choose the single best answer)
O Blast/explosion
O Military training
O Fighting with someone
O Bullet/fragment
O Playing sports/recreation activity/PT
O Other
O Motor vehicle crash
O Fall
O Don’t know
Right after the injury, were you dazed?
O No
O Yes
O Don’t know
How long did it last?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
Right after the injury, were you confused or not thinking clearly?
O No
O Yes
O Don’t know
How long did it last?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
Were you unable to remember things that happened right before the injury, the actual injury itself, and/or things that happened right after the injury?
O No
O Yes
O Don’t know
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?
O Less than 1 hour
O 1 hour to 24 hours
O More than 24 hours but less than 7 days
O 7 days or more
O Don’t know
Were you unconscious or knocked out?
O No
O Yes
O Don’t know
How long were you unconscious or knocked out?
O Less than 1 minute
O 1 minute but less than 10 minutes
O 10 minutes but less than 30 minutes
O 30 minutes but less than 24 hours
O 24 hours or more
O Don’t know
When this injury happened, were any parts of your body injured OTHER THAN your head?
O No
O Yes
O Don’t know
Did this injury disrupt your personal and/or work activities for more than 1 day?
O No
O Yes
O Don’t know
Did you get a medical evaluation/treatment for this injury?
O No
O Yes
O Don’t know
Where did you get evaluated/treated? (Check all that apply)
O In the field by a medic
O Outpatient clinic/doctor’s office
O Emergency room/urgent care center
O Admitted to the hospital as an INPATIENT how many nights? ___
O Don’t know
VETERAN’S SECTION
Are you currently retired or separated from the military?
O No
O Yes
How would you describe your return to civilian life after military service?
O Very Easy
O Somewhat Easy
O Somewhat Difficult
O Very Difficult
How long did it take you to find paid employment after leaving the military?
O Less than 1 month
O 1 to 4 months
O 5 to 8 months
O 9 months to 1 year
O More than 1 year
O I have been pursuing my education or training since leaving the military
O I have not found paid employment
O I have not looked for paid employment
In the first few years after you left the military, did you ever:
-
No
Yes
Did this occur during the first year after you left the military?
Have trouble paying bills?
O
O
Receive unemployment compensation?
O
O
Struggle with alcohol use?
O
O
Struggle with substance use?
O
O
Have trouble finding or keeping housing?
O
O
Have trouble getting medical care for self/family?
O
O
Struggle with hunger or receive help buying food?
O
O
End a serious relationship?
O
O
Have a child (biological, adopted, or foster)?
O
O
Start a business?
O
O
Buy a house?
O
O
Get married?
O
O
Complete your education?
O
O
Tell us about your VA benefits. What VA benefits are you aware of? What benefits have you applied for?
-
I am aware of this benefit
I have applied
I have applied and I have received this benefit
I have applied but I am not eligible for this benefit
I have not applied but I intend to
I have not applied and I do not intend to
VA Home loan guaranty
O
O
O
O
O
O
VA Disability compensation
O
O
O
O
O
O
VA Health benefits
O
O
O
O
O
O
VA Vocational benefits (ex. Veteran Readiness & Employment)
O
O
O
O
O
O
VA Education benefits (ex: GI Bill)
O
O
O
O
O
O
Veteran’s Group Life Insurance (VGI)
O
O
O
O
O
O
VA Caregiver Support Program
O
O
O
O
O
O
We realize that the following questions are very sensitive. Responses to these items are voluntary and you may skip them if you choose. We want to assure you that all of your answers will be kept strictly confidential.
In the past 12 months, how often have you used cannabis (marijuana, pot, grass, hash, etc.)?
O Never
O Less than monthly
O Monthly
O Weekly
O Daily or almost daily
During the past 12 months, what was the primary mode you used marijuana? [Please select one. Did you…]
O Smoke it (for example, in a joint, bong, pipe, or blunt)
O Eat it (for example, in brownies, cakes, cookies, or candy)
O Drink it (for example, in tea, cola, alcohol)
O Vaporize it (for example, in an e-cigarette-like vaporizer or other vaporizing device)
O Dab it (for example, using waxes or concentrates)
O Use it some other way
O Don’t know/Not Sure
O Prefer not to answer
When you used marijuana or hashish during the past 12 months, was it for medical reasons to treat or decrease symptoms of a health condition [such as: nausea, loss of appetite], or was it for non-medical reasons to get pleasure or satisfaction (such as: excitement, to “fit in” with a group, increased awareness, to forget worries, for fun at a social gathering).
O Only for medical reasons to treat or decrease symptoms of a health condition
O Only for non-medical purposes to get pleasure or satisfaction
O Both medical and non-medical reasons
O Don’t know/Not Sure
O Prefer not to answer
In the past 12 months, how often have you used any drugs, including cocaine or crack, heroin, methamphetamine (crystal meth), hallucinogens, or ecstasy/MDMA?
-
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Cocaine, crack, or methamphetamine (crystal meth)
O
O
O
O
O
Heroin
O
O
O
O
O
Hallucinogens
O
O
O
O
O
Ecstasy/MDMA
O
O
O
O
O
In the past 12 months, how often have you used any of the following prescription medications for non-medical reasons (e.g., get high/feel good) or taken more pills than prescribed by a doctor?
-
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
Prescription opiate pain reliever (for example, Percocet, Vicodin, Oxycontin, hydrocodone)
O
O
O
O
O
Prescription medication for anxiety (for example, Xanax, Ativan, Valium, or Klonopin)
O
O
O
O
O
Prescription medication for sleep problems (for example Ambien or Lunesta)
O
O
O
O
O
Prescription medication for ADHD (for example, Adderall, Ritalin)
O
O
O
O
O
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Consigli, Rebecca A CTR USN NAVHLTHRSCHCEN SAN (USA) |
| File Modified | 0000-00-00 |
| File Created | 2025-01-07 |
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