Memo 3

Please place an X next to the response that best fits your choice.

1. What is your gender?

___ Male ___ Female

2. What is your age? ____

3. Are you of Hispanic or Latino origin or descent?

___ Yes, Hispanic ___ No, not Hispanic or Latino

4. In which of the following categories do you feel that you belong? (Please check all that apply)

___ Pacific Islander or Native Hawaiian ___ Black or African/American

___ American Indian or Alaskan Native ___ White

___ Asian ___ Other (Please specify) ___________

5. Was your most recent deployment in support of:

___ OEF (Operation Enduring Freedom) ___ OIF (Operation Iraqi Freedom)

6. When you were deployed, were you:

___ Regular active duty ___ National Guard ___ Reserves

7. What was your primary military occupation during your most recent deployment?
___ Combat arms ___ Combat support ___ Service support

8. What was your branch of the military when you were deployed?

Marines____ Army____ Navy____ Air Force____ Coast Guard ____

9. Did you have an experience during deployment that was so frightening, horrible, or upsetting that, in the past month, you:

a. Have had nightmares about it or thought about it when you did not want to? ___Yes ___No

b. Tried hard not to think about it or went out of your way to avoid situations that reminded you of

it? ___ Yes ___ No

c. Were constantly on guard, watchful, or easily startled? ___ Yes ___No

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

10. Did you have any injury(ies) during your most recent deployment from any of the following?

___ Fragment

___ Bullet

___ Vehicular (any type of vehicle, including airplane)

___ Blast (for example, Improvised Explosive Device, RPG, Land mine, Grenade, etc.)

___ Fall

11. Did any injury you received while you were deployed result in any of the following? Check all that apply.

___ Being dazed, confused or “seeing stars”

___ Not remembering the injury

___ Losing consciousness (knocked out) for less than a minute

___ Losing consciousness for 1-30 minutes

___ Losing consciousness for longer than 30 minutes

___ Symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)

___ Head Injury

___ None of the above