Follow-up Survey

12/19/24, 8:11 PM

Qualtrics Survey Software

Survey Approval
OMB CONTROL NUMBER: 0703-SDOH [TEMPORARY]
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE: The public reporting burden
for this collection of information, [Insert OMB Control
Number], is estimated to average 15 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.

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

1/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Introduction
Thank you for volunteering to complete your follow-up
survey. You are being asked to complete this questionnaire
because you completed our baseline questionnaire
approximately 6 months ago.
Please remember this survey is completely voluntary and
you may stop answering questions at any time.
Do not write any personally identifying information on
this survey.
At the end of the survey you will be redirected to a new
page where you will be able to enter your email address to
claim your gift card if you take this survey while off duty.

Creating Your Unique Identification Code
Creating Your Unique Identification Code
Using this form, please create a unique identification code.
We use this code in place of your name or other personally
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

2/30

12/19/24, 8:11 PM

Qualtrics Survey Software

identifying information to link your questionnaire responses
over time.

1st and 2nd letter of your mother's first name
(Ex: Martha → "MA")
NOTE: if you do not have a woman who you identify as your
mother, use the 1st and 2nd letter of your father's name

Day of your birthday
(Ex: "26," "04")

1st and 2nd letter of the U.S. state you were born. DO
NOT write the state abbreviation.

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

3/30

12/19/24, 8:11 PM

Qualtrics Survey Software

(Ex: Montana → "MO;" Hawaii → "HA")
NOTE: if you were born outside the US, write the first 2 letters
of the country you were born in (Ex: Mexico → "ME")

Last 2 digits of the year you were born
(Ex: 1983 → "83")

1st and 2nd letter of your middle name
(Ex: Alan→ "AL")
NOTE: if you do not have a middle name, write "XX"

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

4/30

12/19/24, 8:11 PM

Qualtrics Survey Software

1st and 2nd letter of the high school you most recently
attended
(Ex: Eagle High School → "EA")
NOTE: if you never attended high school, write "YY"

Participant Characteristics
The first set of survey items ask about your personal
characteristics, your military service history, and other
questions about your employment status.
Please remember this survey is completely voluntary and
you may stop answering questions at any time.
Please avoid including any personally identifiable
information (e.g., names, date of birth) anywhere on
this questionnaire.

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

5/30

12/19/24, 8:11 PM

Qualtrics Survey Software

What is the closest major city that you live nearby?

What is your total household income? This includes the
money you make and the money your partner, spouse, or
other adults who live with you make. Please do not include
basic allowance for housing (BAH) in this total if you
receive one.
$20,000 - $29,999
$30,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $99,999
$100,000 - $124,999
$125,000 - $149,999
$150,000 - $199,999
$200,000 or more
Prefer not to answer

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

6/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Does your current financial condition negatively impact
your military readiness?
Yes
No
Don't know

How many children under the age of 19 live in your
household?

Military Service History
In what branch(es) of the military are you currently serving:
Navy
Marine Corps

Employment

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

7/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Have you had a job in addition to your military job at any
time in the past 6 months for the purpose of earning extra
income?
Yes, I have or have had another job
No, I do not/did not have another job

On average how many hours per week do you work at your
other job?
0-5
6 - 10
11 - 15
16 - 20
20 +

Housing Stability and Community Safety,
Transportation
The next several items ask about where you live and how
you get around.

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

8/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Where do you live?
Barracks
Apartment, condo, or townhouse
Mobile home
Single-family home
Car or vehicle
Hotel or motel
Other:

Do you rent or own?
Rent
Own
Other:

What is your monthly rent or mortgage? (If you do not pay
rent or mortgage, write 0)

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U04…

9/30

12/19/24, 8:11 PM

Qualtrics Survey Software

What is your monthly housing allowance that you get from
the military (also called "basic allowance for housing
(BAH)")? (If you do not receive funding from the military to
pay for your housing, write 0)

Thinking about where you currently live, do you have
problems with any of the following?

a) Broken major
alliances (ex: stove,
fridge)

b) Pests, such as
bugs, ants, mice or
rats

c) Mold or other
fungus

Yes

No

d) Water or gas leaks   
e) Lack of heat or air
conditioning

f) Reliable internet
access

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

10/30

12/19/24, 8:11 PM

Qualtrics Survey Software

g) Crime or other
safety concerns in
your neighborhood

Yes

No

Do you feel physically safe where you currently live?
Yes
No
Prefer not to answer

Do you feel emotionally safe where you currently live?
Yes
No
Prefer not to answer

In the past 6 months, has lack of transportation kept you
from medical appointments, meetings, work, or from
getting things that you need for daily living?
Never
A few times
Several times
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

11/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Frequently

Financial Stability
The next several questions ask about your finances and
ability to pay for certain expenses.

How often over the past 6 months have you had trouble
paying for...

a) Your rent or
mortgage

b) Utilities (ex: gas,
water, electric)

c) Internet or phone
bills

d) Childcare

Never

1 - 2 times

3 - 4 times

Most of the
time

N/A

Food Security

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

12/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Do you currently receive federal food assistance funding,
such as SNAP (Supplemental Nutrition Assistance Program)
funding?
Yes
No
Unsure

Please answer whether the statements were NEVER,
SOMETIMES, or OFTEN TRUE for you and your household in
the last 6 months.

a) You worried that
your food would run
out before you got
money to buy more

Never true

Sometimes
true

Often true

Not applicable

b) The food your
bought just didn't last

and you didn't have
money to get more
c) You were unable
to purchase the
foods you wanted
because you could
not afford them

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

13/30

12/19/24, 8:11 PM

Qualtrics Survey Software

d) You were unable
to purchase fresh
foods, like fresh fruits
and vegetables,
because you could
not afford them

Never true

Sometimes
true

Often true

Not applicable

In the past 6 months, did you or a member of your
household obtain food from any of the following sources?

a) Food pantry

b) Food bank

c) Food donation
program or food
drive

d) Women, Infants,
and Children
Program

e) Donations from
friends or family

f) Another food
donation program

Yes

No

Unsure

You mentioned obtaining food from another food donation
program above (f). What was the food donation program
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

14/30

12/19/24, 8:11 PM

Qualtrics Survey Software

called?

Social Support, Trauma, Discrimination, Racism
The next set of questions asks about experiences you have
had with other people. Some of these questions may make
you feel uncomfortable. If you feel especially
uncomfortable or distressed answering any of the
questions, consider calling your health care provider of the
Veteran's Crisis line (988 +1 or text 838255)

How often do you feel lonely or isolated from those around
you?
Never
Rarely
Sometimes
Often
Always

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

15/30

12/19/24, 8:11 PM

Qualtrics Survey Software

How often do you get the social and emotional support you
need?
Never
Rarely
Sometimes
Often
Always

In the past 6 months, how often did you feel that you,
personally, have been discriminated against because of
your...

a) Gender

b) Sexual
orientation

Never

Rarely

A few
times

Several
times

Frequently

Unsure

Not
applicable

c) Race, ethnicity,

or skin color
d) Age

e) Body size or
other feature of
your body

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

16/30

12/19/24, 8:11 PM

Qualtrics Survey Software

You indicated that you were discriminated against for one
or more of your characteristics. Did this discrimination
occur within a military setting?
Yes
No

If you have been in a relationship in the past 6 months, did
your partner or ex-partner...

a) Insult or talk down
to you

b) Scream or curse
at you

Yes

No

c) Physically hurt you   
d) Force you to have
sex or engage in
sexual activities

In the past 6 months, have you faced any legal issues such
as tenant/landlord, family law, divorce, or child custody?
Yes
No

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

17/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Unsure

Health Care Access and Health Status
The final sets of questions ask about your physical and
emotional health, and your experiences accessing health
care.

Health Care Access
In the past 6 months, was there ever a time when you did
not get health care for a physical health issue (e.g.,
infection, injury) when you needed it?
Yes
No
N/A

You indicated you did not get care when you needed it for
a physical health issue in the past 6 months. Which of

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

18/30

12/19/24, 8:11 PM

Qualtrics Survey Software

these statements explain why you did not get health care?
Rate the degree to which each statement was true for you.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I did not think

treatment would help
I did not know where
to get help

It was too difficult to
schedule an
appointment

I didn't have time

It would have
harmed my career

I could not afford the
cost

I could have been
denied security
clearance in the
future

My supervisor/unit
leadership would not
permit me to miss
work to attend the
appointment

My supervisor/unit
leadership might
have a negative
opinion of me

Members of my unit
might have less
confidence in me

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

19/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I was concerned that
the information I
gave health care

provider might not be
confidential
It would have
negatively affected

my family or personal
life
It was too difficult to
find childcare

I could not find
transportation to get
to the clinic or
hospital

I would think less of
myself if I sought
care

I do not trust health
care providers

Which of the following statements most accurately
describes your history of receiving health care for a mental
health issue over the past 6 months?
I am currently enrolled in care with a health care provider for mental
health-related concerns
I currently meet with a Chaplain for mental health-related concerns

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

20/30

12/19/24, 8:11 PM

Qualtrics Survey Software

I have received care from a health care provider or Chaplain in the past for
mental health-related concerns, but am not currently receiving care
I have never received care from any type of health care provider or
chaplain for mental health-related concerns

In the past 6 months, was there ever a time when you did
not get health care for a mental health issue when you
needed it?
Yes
No
N/A

You indicated you did not get health care when you needed
it in the past 6 months. Which of these statements explain
why you did not get health care? Rate the degree to which
each statement was true for you.

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I did not think

treatment would help
I did not know where
to get help

It was too difficult to
schedule an
appointment

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

21/30

12/19/24, 8:11 PM

Qualtrics Survey Software

I didn't have time

It would have
harmed my career

I could not afford the
cost

I could have been
denied security
clearance in the
future

My supervisor/unit
leadership would not
permit me to miss
work to attend the
appointment

My supervisor/unit
leadership might
have a negative
opinion of me

Members of my unit
might have less
confidence in me

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I was concerned that
the information I
gave the health care   
provider might not be
confidential
It would have
negatively affected

my family or personal
life

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

22/30

12/19/24, 8:11 PM

Qualtrics Survey Software

My commanders or
supervisors
discourage the use
of mental health
services

It was too difficult to
find childcare

I could not find
transportation to get
to the clinic or
hospital

I would think less of
myself

Others would think
less of me

I am worried about
medicines used to
treat mental health
problems

I prefer to try spiritual
or religious
counseling

Strongly
Disagree

Disagree

Neutral

Agree

Strongly
Agree

I do not trust mental

health care providers

Depression (PHQ9)
Over the LAST 2 WEEKS, how often have you been bothered
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

23/30

12/19/24, 8:11 PM

Qualtrics Survey Software

by any of the following problems?

a. Little interest or
pleasure in doing
things

b. Feeling down,
depressed, or
hopeless

c. Trouble falling or
staying asleep, or
sleeping too much

d. Feeling tired or
having little energy

e. Poor appetite or
overeating

f. Feeling bad about
yourself - or that you
are a failure or have
let yourself or your
family down

g. Trouble
concentrating on
things, such as
reading the
newspaper or
watching television

Not at All

Few or Several
Days

More Than Half
the Days

Nearly Every
Day

h. Moving or speaking
so slowly that other
people could have
noticed. Or the
opposite - being

fidgety or restless
that you have been
moving around a lot
more than usual
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

24/30

12/19/24, 8:11 PM

Qualtrics Survey Software

i. Thoughts that you
would be better off
dead or of hurting
yourself in some way

Not at All

Few or Several
Days

More Than Half
the Days

Nearly Every
Day

How difficult have these problems made it for you to do
your wok, take care of things at home, or get along with
other people?
Not at all difficult
Somewhat difficult
Very difficult
Extremely difficult

Anxiety (GAD-2)
Over the LAST 2 WEEKS, how often have you been bothered
by any of the following problems?

a. Feeling nervous,
anxious, or on edge

Not at all

Few or several
days

More than half
the days

Nearly every
day

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

25/30

12/19/24, 8:11 PM

Qualtrics Survey Software

b. Not being able to
stop or control
worrying

Not at all

Few or several
days

More than half
the days

Nearly every
day

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

Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)
Sometimes things happen to people that are unusually or
especially frightening, horrible, or traumatic. For example:
a serious accident or fire
a physical or sexual assault or abuse
an earthquake or flood
a war
seeing someone be killed or seriously injured
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

26/30

12/19/24, 8:11 PM

Qualtrics Survey Software

having a loved one die through homicide or suicide

Have you ever experienced this kind of event?
Yes
No

In the past month, have you...

a. Had nightmares about the event(s) or thought about the
event(s) when you did not want to?
Yes
No

b. Tried hard not to think about the event(s) or went our of
your way to avoid situations that reminded you of the
event(s)?
Yes
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

27/30

12/19/24, 8:11 PM

Qualtrics Survey Software

No

c. Been constantly on guard, watchful, or easily startled?
Yes
No

d. Felt numb or detached from people, activities, or your
surroundings?
Yes
No

e. Felt guilty or unable to stop blaming yourself or others for
the event(s) or any problems the event(s) may have
caused?
Yes
No

How difficult have these problems made it for you to do
your work, take care of things at home, or get along with
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

28/30

12/19/24, 8:11 PM

Qualtrics Survey Software

other people?
Not at all difficult
Somewhat difficult
Very difficult
Extremely difficult

Thank you for your participation
If you need additional support, you can call the National
Crisis Line by dialing 988 at any time.
If you are feeling very upset following taking this survey,
please consider notifying the study principal investigator,
Dr. Kristen Walter (619-553-4108;
[email protected]), calling your health care
provider, or contacting the NHRC IRB (619-552-8482;
[email protected]).
You can contact the following resources for
information about domestic violence services:
Call: 1.800.799.SAFE (7233)
Text: "START" to 88788
Visit: thehotline.org
https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

29/30

12/19/24, 8:11 PM

Qualtrics Survey Software

Visit: https://www.militaryonesource.mil/preventingviolence-abuse/domestic-abuse/domestic-abuse-help/
You can also contact the National Hunger Hotline for
more information about services available for you and
your family:
By Phone: Call the USDA National Hunger Hotline, which
operates from 7:00 AM - 10:00 PM Eastern Time. If you
need for assistance, call 1-866-3-HUNGRY or 1-877-8HAMBRE to speak with a representative who will find
food resources such as meal sites, food banks, and
other social services available near your location
By Text: Text to the automated service at 914-342-7744
with a question that may contain keywords such as
"food," "summer," "meals," etc. to receive an automated
response to resource located near an address and/or
zip code.

Powered by Qualtrics

https://hbsnhrc.gov1.qualtrics.com/Q/EditSection/Blocks/Ajax/GetSurveyPrintPreview?ContextSurveyID=SV_e8waFKDNOjsXbE2&ContextLibraryID=UR_7U0…

30/30