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pdfOMB Number 2900-XXXX
Estimated Burden: 50 MIN
VA Form 10-21087
DEPLOYMENT
EXPERIENCES
PART I
This survey contains questions regarding your experiences before, during, and after military
deployment. No one has had exactly the same experiences that you have had, so your input is very
important. There are no right or wrong answers.
Be sure to answer every statement, and press firmly on the page when circling your responses. If
you want to change your response, please place an “X” over your original answer, and then circle
the more appropriate response.
The survey was prepared with support from the Veterans Affairs Health Services Research &
Development Service, Dr. Dawne S. Vogt, Principal Investigator, the Department of Defense, Drs.
Daniel W. King and Lynda A. King, Co-Principal Investigators, and the National Center for
PTSD. For inquiries or further information, please contact Dr. Dawne Vogt at NCPTSD, 116B-3, VA
Boston, 150 S. Huntington Ave., Boston, MA 02130; Phone: 617-232-9500, ext. 45976;
Email: Dawne.Vogt@va.gov.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collected is in accordance with the
clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to
average 50 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. No person will be penalized for failing to
furnish this information if it does not display a currently valid OMB control number. This collection of information is intended to
fulfill the need identified by the Department of Veterans Affairs in their call for the development, improvement, and/or validation of
measures for screening, detection, and diagnosis. Response to this survey is voluntary and failure to furnish this information will
have no effect on any of your benefits.
Privacy Act: The execution of this form does not authorize the release of information other than that specifically described
below. The information requested on this form is solicited under Title 38, U.S.C., Part I, Chapter 5, Section 527. Information from
the data collection will become part of a system of records that complies with the Privacy Act of 1974. This system is identified as
"Veteran, Patient, Employee and Volunteer Research and Development Project Records-VA (34VA11)" as set forth in the
Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.
DEPLOYMENT EXPERIENCES PT I
VA Form 10-21087
OMB Number 2900-XXXX
Estimated Burden: 50 MIN.
SECTION A: PRE-DEPLOYMENT LIFE EVENTS
The statements below refer to events you may have experienced AT ANY TIME BEFORE YOUR MOST
RECENT DEPLOYMENT. Please circle “Yes” or “No” for each question below.
Before I was deployed, I experienced…
1. ...a natural disaster (for example, a flood or hurricane), a fire, or an accident in which I
was hurt or my property was damaged.
2. ...exposure to a toxic substance (such as dangerous chemicals, radiation).
3. ...combat or exposure to a war zone (in the military or as a civilian).
4. ...the mental illness (for example, clinical depression, anxiety disorder), or lifethreatening physical illness (for example, cancer or heart disease) of someone close to
me.
5. ...a parent who had a problem with drugs or alcohol.
6. ...the death of someone close to me.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
7. ...been through a divorce or been left by a partner or significant other.
Yes
No
8. ...witnessed someone being assaulted or violently killed.
Yes
No
9. ...been robbed or had my home broken into.
Yes
No
10. ...lost my job.
Yes
No
11. ...been emotionally mistreated (for example, shamed, embarrassed, ignored, or repeatedly
told I was no good).
Yes
No
12. ...seen or heard physical fighting between my parents or caregivers.
Yes
No
13. ...been physically punished by a parent or primary caregiver.
Yes
No
14. ...been physically injured by another person (for example, hit, kicked, beaten up).
Yes
No
Before I was deployed, I had...
14a. [IF YES] did this occur (circle all that apply):
15. ...experienced unwanted sexual activity as a result of force, threat of harm, or
manipulation.
15a. [IF YES] did this occur (circle all that apply):
Before I was deployed:
16. ...I experienced a natural disaster (for example, a hurricane), a fire, or an accident in
which I or someone close to me was hurt or had serious property damage.
in
in
childhood adulthood
Yes
No
in
in
childhood adulthood
Yes
No
17. ...someone close to me experienced serious physical or mental health problems.
Yes
No
18. ...a close family member or friend experienced a serious drug or alcohol problem.
Yes
No
19. ...I witnessed someone being seriously assaulted or killed.
Yes
No
20. ...I lost my job or was demoted.
Yes
No
21. ...I was emotionally mistreated by a family member or other loved one (for example,
ignored or repeatedly told I was no good).
Yes
No
22. ...I experienced serious financial problems.
Yes
No
23. ...I experienced serious physical or mental health problems.
Yes
No
24. ...I experienced combat or exposure to a war zone in the military or as a civilian (e.g.,
prior deployment).
Yes
No
25. ...I was seriously physically injured by another person (for example, hit or beaten up).
Yes
No
In
In
childhood adulthood
25a. [IF YES] did this occur (circle all that apply):
SECTION B: CHILDHOOD EXPERIENCES
The sentences below refer to YOUR FAMILY WHEN YOU WERE GROWING UP. Please read each
statement and describe how often it was true for your family by circling the number that best fits your
choice. If you spent time in more than one family setting, please answer these questions about the family in
which you spent the greatest part of your childhood.
Almost
Almost
A few Some of Most of
none of
all of
times the time the time
the time
the time
1. People in my family did things together.
1
2
3
4
5
2. Family members got on each other’s nerves (annoyed each other).
1
2
3
4
5
3. Family members felt uncomfortable with each other.
1
2
3
4
5
4. Family members were there for each other during difficult times.
1
2
3
4
5
5. Family members felt very close to each other.
1
2
3
4
5
6. Family members avoided each other.
1
2
3
4
5
7. When problems arose, family members compromised.
1
2
3
4
5
8. Family members were afraid to say what was on their minds.
1
2
3
4
5
9. There was fighting among family members.
1
2
3
4
5
10. Family members yelled when they were angry with each other.
1
2
3
4
5
11. Family members discussed their personal problems with each other.
1
2
3
4
5
12. Family members shared household responsibilities.
1
2
3
4
5
13. Family members were affectionate with each other.
1
2
3
4
5
14. Family members got on each other’s nerves.
1
2
3
4
5
15. Family members insulted or swore at each other.
1
2
3
4
5
16. Family members were critical of each other.
1
2
3
4
5
SECTION C: FAMILY’S PREPAREDNESS FOR DEPLOYMENT
Below are several statements about different preparations military personnel who have spouses or
significant others and/or children may make prior to deployment, if time allows. Please circle “Yes,” “No,”
or “NA” (Not Applicable) for each statement below. PLEASE SKIP TO SECTION D IF YOU DID NOT
HAVE A SPOUSE OR SIGNIFICANT OTHER AND/OR CHILDREN WHEN YOU DEPLOYED.
Before I deployed:
1. ...a tentative plan was made for how my family would stay in touch (for example,
phone, mail, video, etc.).
2. ...family members were told who to contact to get information about my unit’s safety.
Yes
No
NA
Yes
No
NA
3. ...my family discussed what was and was not OK to talk about during the deployment
(for example, exposure to dangerous situations in the war-zone, problems at home).
Yes
No
NA
4. ...a plan was made for how household maintenance tasks would be managed.
Yes
No
NA
5. ...arrangements were made to ensure that there would be enough money to cover
expenses at home.
Yes
No
NA
6. ...a plan was made for how to handle any financial problems that might come up.
Yes
No
NA
7. ...my family agreed on how money would be spent.
Yes
No
NA
8. ...my family discussed where to get help for different problems that might come up (for
example, if home or car repairs were needed).
Yes
No
NA
9. ...my family talked about how we would manage any conflicts that came up.
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
Yes
No
NA
10. ...my family discussed where they should go for help (for example, another family
member or friend) in case there was an emergency.
11. ...a backup childcare or other care plan was made for family dependents (for example,
who would care for child(ren) if family members were unable to).
12. ...my spouse or significant other and I explained what was going to happen during the
deployment to our child(ren).
13. ...my spouse or significant other and I talked to our child(ren) about how their activities
or responsibilities would change during the deployment.
SECTION D: DEPLOYMENT ENVIRONMENT
The next set of statements is about the conditions of day-to-day life DURING DEPLOYMENT. Please read
each statement and describe what amount of time you were exposed to each condition over the course of the
entire time you were deployed. Circle the number that best fits your choice.
Almost
Almost
A few Some of Most of
none of
all of
times the time the time
the time
the time
1. The climate was extremely uncomfortable.
1
2
3
4
5
2. I had to deal with annoying animals, insects, or plants during my
deployment.
1
2
3
4
5
3. I had access to clean clothing when I needed it.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6. The conditions I lived in were extremely unsanitary.
1
2
3
4
5
7. I had access to bathrooms or showers when I needed them.
1
2
3
4
5
8. I got as much sleep as I needed.
1
2
3
4
5
9. The living space was too crowded.
1
2
3
4
5
10. I was able to get enough privacy.
1
2
3
4
5
11. The workdays were too long.
1
2
3
4
5
12. I got the R&R (rest and relaxation) that I needed.
1
2
3
4
5
13. I got my mail in a timely manner.
1
2
3
4
5
4. I could get a cold drink (for example, water, juice, etc.) when I
wanted one.
5. The food I had to eat was of very poor quality (for example, bad or old
MREs).
Almost
Almost
A few Some of Most of
none of
all of
times the time the time
the time
the time
14. I was exposed to awful smells.
1
2
3
4
5
15. I was subjected to loud noises.
1
2
3
4
5
16. I had to hassle with putting on and taking off NBC equipment.
1
2
3
4
5
17. I had the equipment or supplies to do what I needed to do.
1
2
3
4
5
18. My daily activities were restricted because of local religious or ethnic
customs.
1
2
3
4
5
19. I felt comfortable living in the culture or cultures where I was deployed.
1
2
3
4
5
20. Pressure to conform to the local culture made it difficult for me to do
my job.
1
2
3
4
5
21. I was able to get some rest when I needed it.
1
2
3
4
5
22. I could email home when I needed to.
1
2
3
4
5
23. I could call home when I needed to.
1
2
3
4
5
24. I had to hassle with putting on and taking off heavy or annoying gear.
1
2
3
4
5
25. I was exposed to insects, parasites, or other creatures that could harm
me.
1
2
3
4
5
26. The local culture made it difficult for me to do my job.
1
2
3
4
5
27. I had enough time to myself.
1
2
3
4
5
28. I was not allowed to do the things I needed to do to get my job done.
1
2
3
4
5
29. The nature of my work or routine was often very boring.
1
2
3
4
5
30. My activities during deployment were meaningful to me.
1
2
3
4
5
31. I had adequate shelter from uncomfortable living conditions (for
example, heat, cold, wet, etc.).
1
2
3
4
5
SECTION E: MISSION CHALLENGES
Please rate the extent to which you agree with the following statements about your deployment experience.
Indicate your agreement with each statement by circling the response that best fits your experience.
Neither
Not
Strongly Somewhat
Somewhat Strongly
agree nor
applicable disagree disagree
agree
agree
disagree
1. I was confused by the rules of engagement.
0
1
2
3
4
5
2. I was concerned that the locals could not be trusted.
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
3. I felt as if our humanitarian efforts didn’t make a
difference.
4. I was frustrated by limits placed on when I could use my
weapon.
5. I felt as if our efforts to rebuild war-torn areas were a
waste of time.
6. I felt as if efforts to help the locals (for example,
Neither
Not
Strongly Somewhat
Somewhat Strongly
agree nor
applicable disagree disagree
agree
agree
disagree
providing food and supplies) didn’t make a difference.
7. I was concerned that civilians might actually be
combatants in disguise.
8. I worried that enemy combatants would target civilians
as punishment for their contact with American
personnel.
9. I felt as if the locals did not want the help of American
forces.
10. I felt as if our mission was a waste of time, money, or
lives.
11. I worried that I would be criticized by my superiors for
not following the rules of engagement.
12. I was concerned that I would be punished by the
military for trying to do my job.
13. I was concerned that locals who were supposed to be
helping us were actually working against us.
14. I was frustrated by repeated changes to the rules of
engagement.
15. I felt as if we made little or no positive impact on
civilians’ lives.
16. I was concerned about being trapped in the crossfire of
local nationals.
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
17. I felt that our humanitarian efforts were not appreciated.
0
1
2
3
4
5
18. The rules of engagement made it hard for me to do my
job.
0
1
2
3
4
5
SECTION F: COMBAT EXPERIENCES
The statements below are about your combat experiences during deployment. As used in these statements,
the term “unit” refers to those you lived and worked with on a daily basis during deployment. Please circle
“yes” if the statement is true or “no” if the statement is false.
While deployed:
1. I went on combat patrols or missions.
2. I or members of my unit encountered land or water mines and/or booby traps.
3. I or members of my unit received hostile incoming fire from small arms, artillery, rockets,
mortars, or bombs.
4. I or members of my unit received "friendly" incoming fire from small arms, artillery, rockets,
mortars, or bombs.
5. I was in a vehicle (for example, a truck, tank, APC, helicopter, plane, or boat) that was under fire.
6. I or members of my unit were attacked by terrorists or civilians.
7. I was part of a land or naval artillery unit that fired on the enemy.
8. I was part of an assault on entrenched or fortified positions.
9. I took part in an invasion that involved naval and/or land forces.
10. My unit engaged in battle in which it suffered casualties.
11. I personally witnessed someone from my unit or an ally unit being seriously wounded or killed.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
12. I personally witnessed soldiers from enemy troops being seriously wounded or killed.
Yes
13. I was wounded or injured in combat.
Yes
14. I fired my weapon at the enemy.
Yes
15. I killed or think I killed someone in combat.
Please describe how often you experienced each circumstance by circling the number that best fits your
choice.
Never
While deployed:
16. I encountered land or water mines, booby traps, or roadside
bombs (for example, IEDs).
17. My unit received hostile incoming fire.
18. My unit received "friendly" incoming fire.
19. I was in a vehicle (for example, a “humvee,” helicopter, or
boat) or part of a convoy that was attacked.
20. I was part of a land or naval artillery unit that fired on enemy
combatants.
21. My unit suffered casualties.
22. I personally witnessed enemy combatants being seriously
wounded or killed.
23. I personally witnessed civilians (for example, women and
children) being seriously wounded or killed.
24. I was wounded in combat.
25. I fired my weapon at enemy combatants.
26. I wounded or think I wounded someone during combat
operations.
27. I killed or think I killed someone during combat operations.
While deployed:
28. I was involved in locating or disarming explosive devices.
29. I was involved in searching or clearing homes or buildings.
30. A unit member I knew went missing in action or was taken
prisoner/hostage.
31. I participated in hand-to-hand combat.
32. I experienced a “close call” or attack by an enemy combatant
(for example, an insurgent) disguised as a civilian.
No
No
No
No
A few times A few
A few
Daily or
over entire times each times each almost
deployment month
week
daily
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
A few times A few
A few
Daily or
Never over entire times each times each almost
deployment month
week
daily
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
SECTION G: POST-BATTLE EXPERIENCES
Next are statements about your exposure to the consequences of warfare. As used in these statements, the
term “unit” refers to those you lived and worked with on a daily basis during deployment. Please indicate if
you ever experienced the following events anytime while you were deployed by circling either “yes” or “no.”
1. I observed homes or villages that had been destroyed.
Yes
No
2. I saw refugees who had lost their homes and belongings as a result of battle.
Yes
No
3. I saw people begging for food.
Yes
No
4. I or my unit took prisoners of war.
Yes
No
5. I interacted with enemy soldiers who were taken as prisoners of war.
Yes
No
6. I was exposed to the sight, sound, or smell of animals that had been wounded or killed from
war-related causes.
Yes
No
7. I took care of injured or dying people.
Yes
No
8. I was involved in removing dead bodies after battle.
Yes
No
9. I was exposed to the sight, sound, or smell of dying men and women.
Yes
No
10. I saw enemy soldiers after they had been severely wounded or disfigured in combat.
Yes
No
11. I saw the bodies of dead enemy soldiers.
Yes
No
12. I saw civilians after they had been severely wounded or disfigured.
Yes
No
13. I saw the bodies of dead civilians.
Yes
No
14. I saw Americans or allies after they had been severely wounded or disfigured in combat.
Yes
No
15. I saw the bodies of dead Americans or allies.
Yes
No
Please indicate if you ever experienced the following events anytime while you were deployed by circling
either “Yes” or “No” for each question below.
A few times A few
A few
Daily or
Never over entire times each times each almost
deployment month
week
daily
16. I observed homes or communities that had been destroyed.
1
2
3
4
5
17. I saw refugees who had lost their homes and belongings.
1
2
3
4
5
18. My unit took detainees or prisoners of war.
1
2
3
4
5
19. I interacted with detainees or prisoners of war.
1
2
3
4
5
20. I was exposed to the sight, sound, or smell of dead or dying
animals.
1
2
3
4
5
21. I was involved in handling human remains.
1
2
3
4
5
22. I saw enemy combatants after they had been severely wounded
or disfigured.
1
2
3
4
5
23. I saw the bodies of dead enemy combatants.
1
2
3
4
5
24. I saw Americans or allies after they had been severely wounded
or disfigured.
1
2
3
4
5
25. Someone I cared about was killed.
1
2
3
4
5
SECTION H: EXPOSURE TO NUCLEAR, BIOLOGICAL, CHEMICAL AGENTS
Next are some statements about nuclear, biological, and chemical agents (NBCs) that you may have been
exposed to during the time you were preparing for deployment or during your deployment. Please circle
“Yes,” “No,” or “Don’t know” for each question below.
Either in preparation for or during my deployment…
1. ...I took pyridostigmine or little white pills in foil packets, sometimes called NAPPs, which
Yes
are used to protect against nerve gas.
No
Don’t
know
2. ...I received preventative vaccinations by injection (for example, to prevent anthrax or
botulism). [Note: for women, preventative vaccinations may include deprovera (birth
control).]
Yes
No
3. ...I took preventative pills (for example, to protect against nerve gas).
Yes
No
4. ...I received preventative vaccinations by injection (for example, to prevent anthrax or
botulism).
Yes
No
5. ...nerve gas agents (for example, sarin).
Yes
No
6. ...mustard gas or other blistering agents.
Yes
No
7. ...environmental pesticides (for example, from "fogger" trucks).
Yes
No
8. ...pesticides in uniforms.
Yes
No
9. ...pesticides in flea collars.
Yes
No
10. ...government-issued DEET-containing insect repellents.
Yes
No
11. ...non-government issued insect repellents (for example, Avon Skin-So-Soft, Off).
Yes
No
12. ...smoke or other air pollution.
Yes
No
13. ...diesel or other petrochemical fuel on my skin.
Yes
No
14. ...fumes or exhaust from heaters or generators, including heaters in tents.
Yes
No
15. ...depleted uranium in munitions.
Yes
No
16. ...burning trash or burning feces.
Yes
No
17. ...chlorine gas.
Yes
No
18. ...pesticides (for example, in flea collars, uniforms, or the environment).
Yes
No
19. ...local food other than that provided by the Armed Forces.
Yes
No
20. ...poisoned food.
Yes
No
21. ...I was within 1 km of an exploding artillery shell.
Yes
No
22. ...I was within 5 km of an exploding missile.
Yes
No
23. ...I entered an enemy bunker or military facility.
Yes
No
24. ...I climbed inside an enemy tank that had been abandoned or burned out.
Yes
No
25. ...I was exposed to chemical or biological weapons.
Yes
No
26. ...I was within 5 km of an exploding missile or mortar, or attack by a rocket-propelled
grenade (RPG).
Yes
No
Don’t
know
Don’t
know
Don’t
know
While I was deployed, I was exposed to…
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
While I was deployed…
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
SECTION I: DEPLOYMENT CONCERNS
The statements below are about the amount of danger you felt you were exposed to while you were
deployed. As used in these statements, the term “unit” refers to those you lived and worked with on a daily
basis during deployment. Please describe how much you agree or disagree with each statement by circling
the number that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. I thought I would never survive.
1
2
3
4
5
2. I felt safe.
1
2
3
4
5
3. I was extremely concerned that the enemy would use nuclear,
biological, chemical agents (NBCs) against me.
1
2
3
4
5
4. I felt that I was in great danger of being killed or wounded.
1
2
3
4
5
5. I was concerned that my unit would be attacked by the enemy.
1
2
3
4
5
6. I worried about the possibility of accidents (for example, friendly fire
or training injuries in my unit).
1
2
3
4
5
7. I was afraid I would encounter a mine or booby trap.
1
2
3
4
5
8. I felt secure that I would be coming home after the war.
1
2
3
4
5
9. I thought that vaccinations I received would actually cause me to be
sick.
10. I was concerned that the tablets I took to protect me would make me
sick.
11. I felt that I would become sick from the pesticides or other routinely
used chemicals.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
12. I was concerned about the health effects of breathing bad air.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
22. I was concerned about the effects of breathing bad air.
1
2
3
4
5
23. I worried about exposure to depleted uranium in munitions.
1
2
3
4
5
13. I thought that exposure to depleted uranium would negatively affect
my health.
14. I was afraid that the equipment I was given to protect me from
nuclear, biological, chemical agents (NBCs) would not work.
15. I worried about getting an infectious disease.
16. I was extremely concerned that I would be exposed to nuclear,
biological, or chemical agents (NBC) agents.
17. I felt I was in great danger of being wounded (for example, losing a
limb).
18. I was concerned that my unit would be attacked.
19. I was concerned that I would encounter an explosive device (for
example, a roadside bomb, mine, or booby trap).
20. I was concerned that the medicine I was given to protect me from
illness would make me sick.
21. I felt that I would become sick from pesticides (for example, bug
spray) or other routinely used chemicals.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
24. I feared that the protective gear I was given would not work.
1
2
3
4
5
25. I worried that I would be intentionally hurt by one of my own.
1
2
3
4
5
26. I was concerned that I would be attacked while on convoy or patrol.
1
2
3
4
5
27. I was concerned that a rocket or mortar would hit our living
quarters.
1
2
3
4
5
28. I worried that others in my unit could not keep me safe.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
29. I spent a lot of time worrying about the bad things that could happen
to me.
30. I worried that someone I thought I could trust would turn against
me.
31. I worried that I might be taken hostage.
SECTION J: TRAINING AND DEPLOYMENT PREPARATION
Below are several statements about how well prepared you were by the military for your deployment. As
used in these statements, the term “unit” refers to those you lived and worked with on a daily basis during
deployment. Please describe how much you agree or disagree with each statement by circling the number
that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. I had the supplies and equipment needed to get my job done.
1
2
3
4
5
2. The equipment I was given functioned the way it was supposed to.
1
2
3
4
5
3. I received adequate training on how to use my equipment.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
8. I was adequately prepared to deal with the region’s climate.
1
2
3
4
5
9. I was accurately informed about what to expect from the enemy.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
4. I knew how to treat animal bites, insect stings, or allergic reactions
to plants in the region.
5. I received adequate training on what to do in case of a nuclear,
biological, or chemical (NBC) attack.
6. I had enough gear to protect myself in case of a nuclear,
biological, or chemical (NBC) attack.
7. I received adequate training on how to perform daily life activities
while wearing nuclear, biological, or chemical (NBC) protective
gear.
10. I saw as much combat as I expected.
11. I was informed about the role my unit was expected to play in the
deployment.
12. When I was deployed I had a pretty good idea of how long the
mission would take to complete.
13. I was accurately informed of what daily life would be like during
my deployment.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
14. I was adequately trained to work the shifts required of me during
my deployment.
1
2
3
4
5
15. I had enough gear to protect myself in case of an attack.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
19. I had a pretty good idea of how long my deployment would last.
1
2
3
4
5
20. I was accurately informed of what daily life would be like.
1
2
3
4
5
21. My military duties and assignments were what I expected.
1
2
3
4
5
22. My unit was prepared to operate as a team during deployment.
1
2
3
4
5
16. I received adequate training for the nature of the deployment I
experienced.
17. I was accurately informed about what to expect from enemy
combatants.
18. I was trained by people who were knowledgeable and wellinformed about the topics they were covering.
SECTION K: UNIT SUPPORT
The statements below are about your relationships with other military personnel while you were deployed.
As used in these statements, the term “unit” refers to those you lived and worked with on a daily basis
during deployment. Please describe how much you agree or disagree with each statement by circling the
number that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. My unit was like family to me.
1
2
3
4
5
2. I felt a sense of camaraderie between myself and other soldiers
in my unit.
1
2
3
4
5
3. Members of my unit understood me.
1
2
3
4
5
4. Most people in my unit were trustworthy.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
7. I was impressed by the quality of leadership in my unit.
1
2
3
4
5
8. My superiors made a real attempt to treat me as a person.
1
2
3
4
5
9. The commanding officer(s) in my unit were supportive of my
efforts.
1
2
3
4
5
10. I felt like my efforts really counted to the military.
1
2
3
4
5
11. The military appreciated my service.
1
2
3
4
5
12. I was supported by the military.
1
2
3
4
5
13. I felt a sense of camaraderie with other members of my unit.
1
2
3
4
5
5. I could go to most people in my unit for help when I had a
personal problem.
6. My commanding officer(s) were interested in what I thought
and how I felt about things.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
14. Others in my unit understood me.
1
2
3
4
5
15. Other unit members appreciated my efforts.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
18. Unit leaders made a real attempt to treat me as a person.
1
2
3
4
5
19. Unit leaders supported the decisions I made during deployment.
1
2
3
4
5
20. I felt like my efforts really counted to the military leadership.
1
2
3
4
5
21. My service was appreciated by the military leadership.
1
2
3
4
5
22. I was supported by the military leadership.
1
2
3
4
5
16. Other unit members were there to “back me up” if things went
wrong.
17. Unit leaders were interested in what I thought and how I felt
about things.
SECTION L: RELATIONSHIPS WITHIN UNIT
The next set of questions is again about your relationships with other military personnel while deployed.
Please describe how often you experienced each circumstance by circling the number that best fits your
choice.
While I was deployed, military leaders or other service members:
Never
Once or
Sometimes
twice
Many
times
1. …treated me in an overly critical way.
1
2
3
4
2. …behaved in a way that was uncooperative when working with me.
1
2
3
4
3. ... treated me as if I had to work harder than others to prove myself.
1
2
3
4
4. ... questioned my abilities or commitment to perform my job effectively.
1
2
3
4
5. ... acted as though my mistakes were worse than others.
1
2
3
4
6. …tried to make my job more difficult to do.
1
2
3
4
7. ..."put me down" or treated me in a condescending way.
1
2
3
4
8. ... gossiped about my sex life or spread rumors about my sexual activities.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
13. ...made unwanted attempts to have sex with me.
1
2
3
4
14. ...forced me to have sex.
1
2
3
4
9. ... made crude and offensive sexual remarks directed at me, either publicly
or privately.
10. ... offered me some sort of reward or special treatment to take part in sexual
behavior.
11. ... threatened me with some sort of retaliation for not being sexually
cooperative (for example, the threat of a negative review, physical
violence, or to ruin my reputation).
12. ... made unwanted attempts to stroke or fondle me (for example, stroking my
leg or neck).
Never
While I was deployed, military leaders or other service members:
Once or
Sometimes
twice
Many
times
15. ...threatened my physical safety.
1
2
3
4
16. ...spread negative rumors about my sexual activities.
1
2
3
4
17. ...pressured me into unwanted sexual activity.
1
2
3
4
18. ...threatened me with some sort of retaliation for not being sexually
cooperative (for example, the threat of a negative review or physical
violence).
1
2
3
4
SECTION M: LIFE & FAMILY CONCERNS
The following set of statements refers to concerns you may have had related to your life and family back
home while you were deployed. These questions do not ask if these events actually occurred, but only how
concerned you were that they might happen while you were deployed. Please describe how concerned you
were by circling the number that best fits your choice.
While I was deployed, I was concerned about:
Not
A great
Not at all A little Moderately
applicable
deal
1. …missing out on a promotion at my job back home.
0
1
2
3
4
2. …missing out on opportunities to start a career while I was away.
0
1
2
3
4
3. …damaging my career because I was overseas for a long time.
0
1
2
3
4
4. …losing touch with my co-workers or supervisors back home.
0
1
2
3
4
4. …being unable to financially support my family while I was away.
0
1
2
3
4
6. …harming my relationship with my spouse/significant other.
0
1
2
3
4
7. …being left by my spouse/significant other.
0
1
2
3
4
8. …missing out on my children’s growth and development while I
was away.
0
1
2
3
4
9. …losing touch with my friends.
0
1
2
3
4
10. …missing important events at home such as birthdays, weddings,
funerals, graduations, etc.
0
1
2
3
4
11. …the well-being of my family or friends while I was away.
0
1
2
3
4
12. …my inability to help my family or friends if they had some type
of problem.
0
1
2
3
4
13. …my inability to directly manage or control family affairs.
0
1
2
3
4
14. …the care that my children were receiving while I was away.
0
1
2
3
4
15. …damaging my career because I was deployed for a long time.
0
1
2
3
4
16. …the care that my child(ren) or other dependents were receiving.
0
1
2
3
4
17. …the care that my pet(s) were receiving.
0
1
2
3
4
18. …being cheated on by my spouse or significant other.
0
1
2
3
4
19. …the safety and well-being of a loved one who was also deployed.
0
1
2
3
4
Not
A great
Not at all A little Moderately
While I was deployed, I was concerned about:
applicable
deal
21. …my family’s ability to manage their stress and worries about my
0
1
2
3
4
safety.
22. …my spouse or significant other’s ability to manage the household
0
1
2
3
4
(for example, chores, bills, home repairs, etc.).
23. …how my finances were being managed.
0
1
2
3
4
SECTION N: FAMILY EVENTS
The next set of statements refers to stressful family events that you may have experienced during your
deployment. Please circle “Yes” or “No” for each question below.
While I was deployed:
1. …I had serious problems getting in touch with a family member or other loved one.
Yes
No
2. …a family member or other loved one suffered a serious physical illness or mental health crisis.
Yes
No
3. …a family member or other loved one had serious legal problems.
Yes
No
4. …a family member or other loved one was injured.
Yes
No
5. …a family member or other loved one was severely mistreated.
Yes
No
6. …a family member or other loved one passed away.
Yes
No
7. …my family had serious money problems.
Yes
No
8. …a spouse or significant other cheated on me.
Yes
No
9. …a spouse or significant other heard that I had cheated on him/her.
Yes
No
10. …my relationship with a spouse or significant other ended.
Yes
No
11. …I had a major conflict with a family member or other loved one.
Yes
No
12. …I stopped hearing from a family member or other loved one.
Yes
No
13. …my family or other loved ones had serious difficulty adjusting to my absence.
Yes
No
14. …my home was robbed or broken into.
Yes
No
15. …my money or belongings were stolen.
Yes
No
16. …a family member or other person I trusted stole or wasted my money.
Yes
No
17. …I learned that a loved one was doing things I disapproved of.
Yes
No
18. …a family member or other loved one was also deployed.
Yes
No
19. …a family member got into serious trouble at home, at school, or in the community.
Yes
No
SECTION O: SUPPORT FROM FAMILY/FRIENDS
The next set of statements refers to social support from family or friends during your deployment. Please
describe how much you agree or disagree with each statement by circling the number that best fits your
choice.
During my deployment:
1. ...I was carefully listened to by family members or friends.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1
2
3
4
5
During my deployment:
2. ...I had family members or friends back home who were proud of
my service to my country.
3. ...Among my friends or relatives, there was someone who made me
feel better when I was feeling down.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1
2
3
4
5
1
2
3
4
5
4. ...I had problems that I could not discuss with family or friends.
1
2
3
4
5
5. ...Among my friends or relatives, there was someone I could talk to
when I needed good advice.
1
2
3
4
5
6. ...People at home just did not understand what I was going through.
1
2
3
4
5
7. ...My friends and family respected my role in the Armed Forces.
1
2
3
4
5
8. ...I had friends or relatives to look out for my family or other
dependents (including pets), or take care of my finances,
property, or belongings if needed.
1
2
3
4
5
9. ...I was disappointed by how little communication I got from home.
1
2
3
4
5
10. ...I was disappointed by how little support I got from home.
1
2
3
4
5
11. ...There were people at home who cared about me.
1
2
3
4
5
12. ...I had friends or family members I could talk to about my
deployment experiences.
1
2
3
4
5
SECTION P: POSTDEPLOYMENT REINTEGRATION
You have completed the questions about your deployment. The next set of statements relates to experiences
that you may have had in the process of readjusting/reintegrating into life at home after deployment. Please
describe how much you agree or disagree with each statement as it reflects your experiences IN THE FIRST
THREE MONTHS AFTER YOU RETURNED FROM DEPLOYMENT by circling the number that best
fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. The transition back from deployment went smoothly.
1
2
3
4
5
2. I was frustrated by people asking me questions about my
deployment.
1
2
3
4
5
3. Finding a job or returning to work or school was difficult for me.
1
2
3
4
5
4. I was happy at work or school.
1
2
3
4
5
5. I had trouble getting along with others at work or school.
1
2
3
4
5
6. Other people’s complaints about their daily lives irritated me.
1
2
3
4
5
7. I felt more comfortable talking to my military buddies than my
friends or family.
1
2
3
4
5
8. I had trouble dealing with people who reminded me of the enemy.
1
2
3
4
5
9. I didn’t feel needed by friends, family, or coworkers anymore.
1
2
3
4
5
1
2
3
4
5
10. I felt like I was in the way around my friends and family.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
11. I no longer fit in with my friends and family.
1
2
3
4
5
12. I had trouble relaxing around friends and family.
1
2
3
4
5
13. I enjoyed doing the things I used to do.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
16. People bothered or annoyed me more than they used to.
1
2
3
4
5
17. People voiced opinions about the deployment that made me angry.
1
2
3
4
5
18. I found it hard to be around old friends.
1
2
3
4
5
19. I had an easy time making new friends.
1
2
3
4
5
20. Someone I once relied on for support was no longer around.
1
2
3
4
5
14. I spent a lot of time watching TV shows, listening to radio
programs, or reading articles about the war.
15. It was hard for me to stop thinking about things that happened
during the deployment.
SECTION Q: POSTDEPLOYMENT SUPPORT
You have completed the questions about your deployment. The next set of statements refers to social
support after deployment. Please decide how much you agree or disagree with each statement and circle the
number that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. The reception I received when I returned from my deployment
made me feel appreciated for my efforts.
2. The American people made me feel at home when I returned.
3. When I returned, people made me feel proud to have served my
country in the Armed Forces.
4. I am carefully listened to and understood by family members or
friends.
5. Among my friends or relatives, there is someone who makes me
feel better when I am feeling down.
6. I have problems that I can't discuss with family or friends.
7. Among my friends or relatives, there is someone I go to when I
need good advice.
8. People at home just don't understand what I have been through
while in the Armed Forces.
9. There are people to whom I can talk about my deployment
experiences.
10. The people I work with respect the fact that I am a veteran.
11. My supervisor understands when I need time off to take care of
personal matters.
12. My friends or relatives would lend me money if I needed it.
13. My friends or relatives would help me move my belongings if I
needed to.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
14. When I am unable to attend to daily chores, there is someone
who will help me with these tasks.
15. When I am ill, friends or family members will help out until I am
well.
16. The reception I received from my family made me feel
appreciated for my efforts.
17. The reception I received from members of my community made
me feel appreciated for my efforts.
18. The people I work with respect the fact that I served my country.
19. I am carefully listened to by family members or friends.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
SECTION R: POSTDEPLOYMENT FAMILY EXPERIENCES
The sentences below refer to family experiences for military personnel who are CURRENTLY married or
living with other family members. Please describe how much you agree or disagree with each statement by
circling the number that best fits your choice. If you spend time in more than one family setting, please
answer these questions about the family in which you spend the greatest amount of time.
PLEASE SKIP TO SECTION S IF YOU ARE NOT MARRIED OR LIVING WITH OTHER FAMILY
MEMBERS.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. People in my family do things together.
1
2
3
4
5
2. Family members get on each other’s nerves.
1
2
3
4
5
3. Family members feel uncomfortable with each other.
1
2
3
4
5
4. Family members are there for each other during difficult times.
1
2
3
4
5
5. Family members feel very close to each other.
1
2
3
4
5
6. Family members avoid each other.
1
2
3
4
5
7. When problems arise, family members compromise.
1
2
3
4
5
8. Family members are afraid to say what is on their minds.
1
2
3
4
5
9. There is fighting among family members.
1
2
3
4
5
10. Family members yell when they are angry with each other.
1
2
3
4
5
11. Family members discuss their personal problems with each
other.
1
2
3
4
5
12. Family members share household responsibilities.
1
2
3
4
5
13. Family members are affectionate with each other.
1
2
3
4
5
14. Family members insult or swear at each other.
1
2
3
4
5
15. Family members are critical of each other.
1
2
3
4
5
SECTION S: POST-DEPLOYMENT LIFE EVENTS
The next statements refer to events you may have experienced SINCE RETURNING FROM YOUR
DEPLOYMENT. These questions are similar to the items you’ve answered previously about events
before your deployment. For this page, please circle “Yes” or “No” for each question below.
Since returning home, I have experienced…
1. ...a natural disaster (for example, a flood or hurricane), a fire, or an accident in which I was hurt
Yes
or my property was damaged.
No
2. ...exposure to a toxic substance (such as dangerous chemicals or radiation).
Yes
No
3. ...combat or exposure to a war-zone (in the military or as a civilian).
Yes
No
4. ...a serious operation.
Yes
No
5. ...a mental illness (for example, clinical depression or anxiety disorder), or life-threatening
physical illness (for example, cancer or heart disease) of someone close to me.
Yes
No
6. ...the death of someone close to me.
Yes
No
7. ...experienced stressful legal problems (for example, being sued or suing someone else).
Yes
No
8. ...witnessed someone being assaulted or violently killed.
Yes
No
9. ...been robbed or had my home broken into.
Yes
No
10. ...had a family member with a serious drug or alcohol problem.
Yes
No
11. ...been unemployed and seeking employment for at least 3 months.
Yes
No
12. ...been emotionally mistreated (for example, shamed, embarrassed, ignored, or repeatedly told I
was no good).
Yes
No
13. ...experienced unwanted sexual activity as a result of force, threat of harm, or manipulation.
Yes
No
14. ...been physically injured by another person (for example, hit, kicked, or beaten up).
Yes
No
15. ...lost my job.
Yes
No
16. ...gone through a divorce or been left by a partner or significant other.
Yes
No
17. ...had problems getting access to adequate healthcare.
Yes
No
Yes
No
19. ...someone close to me has experienced serious physical or mental health problems.
Yes
No
20. ...a close family member or friend has experienced a serious drug or alcohol problem.
Yes
No
21. ...I have witnessed someone being seriously assaulted or killed.
Yes
No
22. ...I have lost my job or been demoted.
Yes
No
23. ...I have been emotionally mistreated by a family member or other loved one (for example,
ignored or repeatedly told I was no good).
Yes
No
24. ...I have experienced serious financial problems.
Yes
No
Since returning home, I have...
Since returning home:
18. ...I have experienced a natural disaster (for example, a hurricane), a fire, or an accident in which
I or someone close to me was hurt or had serious property damage.
25. ...I have experienced serious physical or mental health problems.
Yes
No
26. ...I have experienced stressful legal problems (for example, being sued, suing someone else, or
being in a custody battle).
Yes
No
27. ...I have been seriously physically injured by another person (for example, hit or beaten up).
Yes
No
SECTION U: POST-DEPLOYMENT DISTRESS
The following statements refer to feelings you may have had since returning from your deployment. Please
think about the event or events that were most disturbing to you while you were deployed and respond to the
statements about experiences or feelings you have had IN THE LAST THREE MONTHS. Circle the number
that best fits your choice.
In the last three months I have been bothered by...
Not at all
A little
Quite a
Moderately
Extremely
bit
bit
1. ...repeated, disturbing memories of my military experiences.
1
2
3
4
5
2. ...repeated, disturbing dreams of my military experiences.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
5. ...trouble remembering important parts of my military experiences.
1
2
3
4
5
6. ...loss of interest in activities that I used to enjoy.
1
2
3
4
5
7. ...feeling distant or cut off from other people.
1
2
3
4
5
8. ...feeling emotionally numb, or being unable to have loving
feelings for those close to me.
1
2
3
4
5
9. ...feeling as if my future will somehow be cut short.
1
2
3
4
5
10. ...trouble falling or staying asleep.
1
2
3
4
5
11. ...feeling irritable or having angry
outbursts.
1
2
3
4
5
12. ...having difficulty concentrating.
1
2
3
4
5
13. ...being “super alert,” or watchful or on guard.
1
2
3
4
5
14. ...feeling jumpy or easily startled.
1
2
3
4
5
15. ...having physical reactions when something reminds me of my
military experiences.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
3. ...suddenly acting or feeling as if my military experiences were
happening again.
4. ...feeling very upset when something happened that reminded me
of my military experiences.
In the past three months, I have tried to:
16. ...avoid thinking about my military experiences, or avoid having
feelings about them.
17. ...avoid activities or situations because they reminded me of my
military experiences.
SECTION V: ADDITIONAL SURVEY INFORMATION
Please check the appropriate response or fill in the required information.
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. What is the highest level of education you have attained?
___ 8th grade or less
___ Some high school
___ High school graduate
___ Vocational or technical training
___ Some college
___ Four-year college graduate
___ Some graduate or professional school
___ Graduate or professional degree
6. What is your current marital status?
___ Married
___ Living as a couple
___ Separated
___ Divorced
___ Widowed
___ Single/Never married
7. Which of the following categories best describes your 2006 household income before taxes?
___ $15,000 or less
___ $50,001 to $75,000
___ $15,001 to $25,000
___ $75,001 to $100,000
___ $25,001 to $35,000
___ Over $100,000
___ $35,001 to $50,000
8. Are you currently serving in the military either on active duty or with the National Guard or Reserves?
___ Yes
___ No
8a. (If Yes) Are you currently:
___ Regular active duty
___ National Guard
___ Reserves
9. Have you ever or are you currently applying for service-connected disability status?
___ Yes
___ No
9a. (If yes, in past) Did you receive service-connected disability status?
___ Yes
___ No
10. During what time period was your most recent deployment to Iraq or Afghanistan?
From ____/____/____ (month/day/year)
To ____/____/____ (month/day/year)
11. Was this most recent deployment in support of:
___ OEF (Operation Enduring Freedom)
___ OIF (Operation Iraqi Freedom)
12. When you were deployed, were you:
___ Regular active duty
___ National Guard
___ Reserves
13. What was your branch of the military when you were deployed?
Marines____ Army____ Navy____
Air Force____ Coast Guard ____
14. What was your military rank when you were deployed (e.g., E-5, O-6)? _____________
15. What was your primary military occupation (MOS, SSI, Rating or NEC, NOBC, or AFSC) when you
were deployed? _____________
16. Please briefly describe what duties your unit performed (e.g. transportation, moving equipment from
ports to front lines).
___________________________________________________________________________
_______________________________________________________________________________________
17. Where were you stationed?
_______________________________________________________________________________________
18. What was your marital status when you deployed?
___ Married
___ Divorced
___ Living as a couple
___ Widowed
___ Separated
___ Single/Never married
19. Did you have any children when you deployed?
___ Yes
___ No
20. Have you had children since you deployed?
___ Yes
___ No
21. IF YES TO EITHER 18 OR 19: How many children do you have and what are their ages?
____________________________________________
21. Do you think that you have in the past or are currently suffering from deployment-related illnesses?
___ No, never
___ Yes, in the past
___ Yes, currently
OMB Number 2900-XXXX
Estimated Burden: 60 MIN
VA Form 10-21087
DEPLOYMENT
EXPERIENCES
PART II
This survey contains questions regarding your experiences before, during, and after military
deployment. No one has had exactly the same experiences that you have had, so your input is very
important. There are no right or wrong answers.
Be sure to answer every statement, and press firmly on the page when circling your responses. If
you want to change your response, please place an “X” over your original answer, and then circle
the more appropriate response.
The survey was prepared with support from the Veterans Affairs Health Services Research &
Development Service, Dr. Dawne S. Vogt, Principal Investigator, the Department of Defense, Drs.
Daniel W. King and Lynda A. King, Co-Principal Investigators, and the National Center for
PTSD. For inquiries or further information, please contact Dr. Dawne Vogt at NCPTSD, 116B-3, VA
Boston, 150 S. Huntington Ave., Boston, MA 02130; Phone: 617-232-9500, ext. 45976;
Email: Dawne.Vogt@va.gov.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collected is in accordance with the
clearance requirements of section 3507 of this Act. The public reporting burden for this collection of information is estimated to
average 60 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. No person will be penalized for failing to
furnish this information if it does not display a currently valid OMB control number. This collection of information is intended to
fulfill the need identified by the Department of Veterans Affairs in their call for the development, improvement, and/or validation of
measures for screening, detection, and diagnosis. Response to this survey is voluntary and failure to furnish this information will
have no effect on any of your benefits.
Privacy Act: The execution of this form does not authorize the release of information other than that specifically described
below. The information requested on this form is solicited under Title 38, U.S.C., Part I, Chapter 5, Section 527. Information from
the data collection will become part of a system of records that complies with the Privacy Act of 1974. This system is identified as
"Veteran, Patient, Employee and Volunteer Research and Development Project Records-VA (34VA11)" as set forth in the
Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.
VA Form 10-21087
OMB Number 2900-0570
Estimated Burden: 60 MIN
DEPLOYMENT EXPERIENCES PART II
SECTION A: THOUGHTS AND ACTIONS
Listed below are a number of statements about how you think and do things. Please read each statement and
decide how true or false it is for you personally. Please circle the number that best fits your choice.
Neither
Very Somewhat
Somewhat Very
true nor
false
false
true
true
false
1) I'm always willing to admit it when I make a mistake.
1
2
3
4
5
2) No matter whom I'm talking to, I'm always a good listener.
1
2
3
4
5
3) I am always courteous, even to people who are disagreeable.
1
2
3
4
5
4) It is sometimes hard for me to go on with my work if I am not encouraged.
1
2
3
4
5
5) I sometimes feel resentful when I don’t get my way.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
8) There have been occasions when I took advantage of someone.
1
2
3
4
5
9) I sometimes try to get even rather than forgive and forget.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
12) I am sometimes irritated by people who ask favors of me.
1
2
3
4
5
13) I have never deliberately said something that hurt someone’s feelings.
1
2
3
4
5
6) On a few occasions, I have given up doing something because I thought too
little of my ability.
7) There have been times when I felt like rebelling against people in authority
even though I knew they were right.
10) I have never been irked when people expressed ideas very different
from my own.
11) There have been times when I was quite jealous of the good fortune of
others.
SECTION B: PREDEPLOYMENT LIFE EVENTS
The statements below refer to events you may have experienced AT ANY TIME BEFORE YOUR MOST
RECENT DEPLOYMENT. Please circle “Yes” or “No” for each question below.
Before I was deployed:
1. ...I witnessed someone being seriously assaulted or killed.
Yes
No
2. ...I was exposed to a toxic substance (such as dangerous chemicals or radiation).
Yes
No
3. ...someone close to me experienced serious physical or mental health problems.
Yes
No
4. ...someone close to me died.
Yes
No
5. ...a close family member or friend experienced a serious drug or alcohol problem.
Yes
No
6. ...I went through a divorce or was left by a significant other.
Yes
No
7. ...I experienced a natural disaster (for example, a hurricane), a fire, or an accident in which I or
someone close to me was hurt or had serious property damage.
Yes
No
8. ...I was robbed or had my home broken into.
Yes
No
9. ...I lost my job or was demoted.
Yes
No
10. ...I was emotionally mistreated by a family member or other loved one (for example, ignored
or repeatedly told I was no good).
Yes
No
11. ...I experienced serious financial problems.
Yes
No
12. ...I experienced serious physical or mental health problems.
Yes
No
13. ...I experienced combat or exposure to a war zone in the military or as a civilian (e.g., prior
deployment).
Yes
No
14. ...I saw or heard physical fighting between my parents or caregivers.
Yes
No
15. ...I was physically punished by a parent or primary caregiver.
Yes
No
16. ...I was seriously physically injured by another person (for example, hit or beaten up).
Yes
No
In
In
childhood adulthood
16a. [IF YES] did this occur (circle all that apply):
17. ...I experienced unwanted sexual activity as a result of force, threat of harm, or manipulation.
Yes
No
In
In
childhood adulthood
17a. [IF YES] did this occur (circle all that apply):
SECTION C: CHILDHOOD EXPERIENCES
The sentences below refer to YOUR FAMILY WHEN YOU WERE GROWING UP. Please read each
statement and describe how often it was true for your family by circling the number that best fits your choice.
If you spent time in more than one family setting, please answer these questions about the family in which you
spent the greatest part of your childhood.
Almost
A few Some of Most of Almost all
none of
times the time the time of the time
the time
1. People in my family did things together.
1
2
3
4
5
2. Family members got on each other’s nerves.
1
2
3
4
5
3. Family members felt uncomfortable with each other.
1
2
3
4
5
4. Family members were there for each other during difficult times.
1
2
3
4
5
5. Family members felt very close to each other.
1
2
3
4
5
6. Family members avoided each other.
1
2
3
4
5
7. When problems arose, family members compromised.
1
2
3
4
5
8. Family members were afraid to say what was on their minds.
1
2
3
4
5
9. There was fighting among family members.
1
2
3
4
5
10. Family members yelled when they were angry with each other.
1
2
3
4
5
11. Family members discussed their personal problems with each other.
1
2
3
4
5
12. Family members shared household responsibilities.
1
2
3
4
5
13. Family members were affectionate with each other.
1
2
3
4
5
14. Family members insulted or swore at each other.
1
2
3
4
5
15. Family members were critical of each other.
1
2
3
4
5
2
SECTION D: FAMILY’S PREPAREDNESS FOR DEPLOYMENT
Below are several statements about different preparations military personnel who have spouses or significant
others and/or children may make prior to deployment, if time allows. Please circle “Yes,” “No,” or “NA” (Not
Applicable) for each statement below. PLEASE SKIP TO SECTION D IF YOU DID NOT HAVE A SPOUSE
OR SIGNIFICANT OTHER AND/OR CHILDREN WHEN YOU DEPLOYED.
Before I deployed:
1. ...a tentative plan was made for how my family would stay in touch (for example, phone,
mail, video, etc.).
Yes
No
Not
applicable
2. ...family members were told who to contact to get information about my unit’s safety.
Yes
No
Not
applicable
3. ...my family discussed what was and was not OK to talk about during the deployment (for
example, exposure to dangerous situations in the war-zone, problems at home).
Yes
No
Not
applicable
4. ...a plan was made for how household maintenance tasks would be managed.
Yes
No
Not
applicable
5. ...arrangements were made to ensure that there would be enough money to cover expenses
at home.
Yes
No
Not
applicable
6. ...a plan was made for how to handle any financial problems that might come up.
Yes
No
7. ...my family agreed on how money would be spent.
Yes
No
8. ...my family discussed where to get help for different problems that might come up (for
example, if home or car repairs were needed).
Yes
No
Not
applicable
9. ...my family talked about how we would manage any conflicts that came up.
Yes
No
Not
applicable
Yes
No
Not
applicable
Yes
No
Not
applicable
Yes
No
Not
applicable
Yes
No
Not
applicable
10. ...my family discussed where they should go for help (for example, another family member
or friend) in case there was an emergency.
11. ...a backup childcare or other care plan was made for family dependents (for example, who
would care for child(ren) if family members were unable to).
12. ...my spouse or significant other and I explained what was going to happen during the
deployment to our child(ren).
13. ...my spouse or significant other and I talked to our child(ren) about how their activities or
responsibilities would change during the deployment.
Not
applicable
Not
applicable
SECTION E: DEPLOYMENT ENVIRONMENT
The next set of statements is about the conditions of day-to-day life DURING DEPLOYMENT. Please read each
statement and describe what amount of time you were exposed to each condition over the course of the entire
time you were deployed. Circle the number that best fits your choice.
Almost
A few Some of Most of Almost all
none of
times the time the time of the time
the time
1. The climate was extremely uncomfortable.
1
2
3
4
5
2. I had to deal with annoying animals, insects, or plants during my
deployment.
1
2
3
4
5
3. I had access to clean clothing when I needed it.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
4. I could get a cold drink (for example, water, juice, etc.) when I
wanted one.
5. The food I had to eat was of very poor quality (for example, bad or
old MREs).
6. The conditions I lived in were extremely unsanitary.
3
Almost
A few Some of Most of Almost all
none of
times the time the time of the time
the time
7. I had access to bathrooms or showers when I needed them.
1
2
3
4
5
8. I got as much sleep as I needed.
1
2
3
4
5
9. The living space was too crowded.
1
2
3
4
5
10. I was able to get enough privacy.
1
2
3
4
5
11. The workdays were too long.
1
2
3
4
5
12. I was able to get some rest when I needed it.
1
2
3
4
5
13. I got my mail in a timely manner.
1
2
3
4
5
14. I could email home when I needed to.
1
2
3
4
5
15. I could call home when I needed to.
1
2
3
4
5
16. I was exposed to awful smells.
1
2
3
4
5
17. I was subjected to loud noises.
1
2
3
4
5
18. I had to hassle with putting on and taking off heavy or annoying gear.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
21. The local culture made it difficult for me to do my job.
1
2
3
4
5
22. I had enough time to myself.
1
2
3
4
5
23. I was not allowed to do the things I needed to do to get my job done.
1
2
3
4
5
24. The nature of my work or routine was often very boring.
1
2
3
4
5
25. My activities during deployment were meaningful to me.
1
2
3
4
5
26. I had adequate shelter from uncomfortable living conditions (for
example, heat, cold, wet, etc.).
1
2
3
4
5
19. I was exposed to insects, parasites, or other creatures that could harm
me.
20. My daily activities were restricted because of local religious or ethnic
customs.
SECTION F: MISSION CHALLENGES
Please rate the extent to which you agree with the following statements about your deployment experience.
Indicate your agreement with each statement by circling the response that best fits your experience.
Neither
Not
Strongly Somewhat
Somewhat Strongly
agree nor
applicable disagree disagree
agree
agree
disagree
1. I was confused by the rules of engagement.
0
1
2
3
4
5
2. I was concerned that the locals could not be trusted.
0
1
2
3
4
5
3. I felt as if our humanitarian efforts didn’t make a difference.
0
1
2
3
4
5
4
Neither
Not
Strongly Somewhat
Somewhat Strongly
agree nor
applicable disagree disagree
agree
agree
disagree
4. I was frustrated by limits placed on when I could use my
weapon.
5. I felt as if our efforts to rebuild war-torn areas were a waste
of time.
6. I felt as if efforts to help the locals (for example, providing
food and supplies) didn’t make a difference.
7. I was concerned that civilians might actually be combatants
in disguise.
8. I worried that enemy combatants would target civilians as
punishment for their contact with American personnel.
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
17. I felt that our humanitarian efforts were not appreciated.
0
1
2
3
4
5
18. The rules of engagement made it hard for me to do my job.
0
1
2
3
4
5
9. I felt as if the locals did not want the help of American forces.
10. I felt as if our mission was a waste of time, money, or lives.
11. I worried that I would be criticized by my superiors for not
following the rules of engagement.
12. I was concerned that I would be punished by the military for
trying to do my job.
13. I was concerned that locals who were supposed to be helping
us were actually working against us.
14. I was frustrated by repeated changes to the rules of
engagement.
15. I felt as if we made little or no positive impact on civilians’
lives.
16. I was concerned about being trapped in the crossfire of local
nationals.
SECTION G: COMBAT EXPERIENCES
The statements below are about your combat experiences during deployment. As used in these statements, the
term “unit” refers to those you lived and worked with on a daily basis during deployment. Please describe how
often you experienced each circumstance by circling the number that best fits your choice.
A few times A few
A few Daily or
Never over entire times each
times
almost
deployment
month each week daily
While deployed:
1. I went on combat patrols or missions.
1
2
3
4
5
2. I encountered land or water mines, booby traps, or roadside bombs
(for example, IEDs).
1
2
3
4
5
3. My unit received hostile incoming fire.
1
2
3
4
5
4. My unit received "friendly" incoming fire.
1
2
3
4
5
5. I was in a vehicle (for example, a “humvee,” helicopter, or boat) or
part of a convoy that was under fire.
1
2
3
4
5
5
While deployed:
6. I was part of a land or naval artillery unit that fired on enemy
combatants.
A few times A few
A few Daily or
Never over entire times each
times
almost
deployment
month each week daily
1
2
3
4
5
7. I took part in an assault on entrenched or fortified positions.
1
2
3
4
5
8. I took part in an invasion that involved naval or land forces.
1
2
3
4
5
9. My unit suffered casualties.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
13. I was wounded in combat.
1
2
3
4
5
14. I fired my weapon at enemy combatants.
1
2
3
4
5
15. I wounded or think I wounded someone during combat operations.
1
2
3
4
5
16. I killed or think I killed someone during combat operations.
1
2
3
4
5
17. I was involved in locating or disarming explosive devices.
1
2
3
4
5
17. I was involved in searching or clearing homes or buildings.
1
2
3
4
5
18. A unit member I knew went missing in action or was taken
prisoner/hostage.
1
2
3
4
5
19. I participated in hand-to-hand combat.
1
2
3
4
5
20. I experienced a “close call” or attack by an enemy combatant (for
example, an insurgent) disguised as a civilian.
1
2
3
4
5
10. I personally witnessed someone from my unit or an ally unit being
seriously wounded or killed.
11. I personally witnessed enemy combatants being seriously wounded
or killed.
12. I personally witnessed civilians (for example, women and children)
being seriously wounded or killed.
SECTION H: POST-BATTLE EXPERIENCES
Next are statements about your exposure to the consequences of warfare. As used in these statements, the term
“unit” refers to those you lived and worked with on a daily basis during deployment. Please indicate if you ever
experienced the following events anytime while you were deployed by circling either “Yes” or “No” for each
question below.
A few times A few
A few Daily or
Never over entire times each times
almost
deployment month each week daily
1. I observed homes or communities that had been destroyed.
1
2
3
4
5
2. I saw refugees who had lost their homes and belongings.
1
2
3
4
5
3. I saw people begging for food.
1
2
3
4
5
4. My unit took detainees or prisoners of war.
1
2
3
4
5
5. I interacted with detainees or prisoners of war.
1
2
3
4
5
6. I was exposed to the sight, sound, or smell of dead or dying animals.
1
2
3
4
5
6
A few times A few
A few Daily or
Never over entire times each times
almost
deployment month each week daily
7. I took care of injured or dying people.
1
2
3
4
5
8. I was involved in handling human remains.
1
2
3
4
5
9. I was exposed to the sight, sound, or smell of dying men or women.
1
2
3
4
5
10. I saw enemy combatants after they had been severely wounded or
disfigured.
1
2
3
4
5
11. I saw the bodies of dead enemy combatants.
1
2
3
4
5
12. I saw civilians after they had been severely wounded or disfigured.
1
2
3
4
5
13. I saw the bodies of dead civilians.
1
2
3
4
5
14. I saw Americans or allies after they had been severely wounded or
disfigured.
1
2
3
4
5
15. I saw the bodies of dead Americans or allies.
1
2
3
4
5
16. Someone I cared about was killed.
1
2
3
4
5
SECTION I: EXPOSURE TO NUCLEAR, BIOLOGICAL, OR CHEMICAL AGENTS
Next are some statements about nuclear, biological, and chemical agents (NBCs) that you may have been
exposed to during the time you were preparing for deployment or during your deployment. Please circle “Yes,”
“No,” or “Don’t know” for each question below.
Either in preparation for or during my deployment:
1. ...I took preventative pills (for example, to protect against nerve gas).
Yes
No
Don’t
know
2. ...I received preventative vaccinations by injection (for example, to prevent anthrax or
botulism).
Yes
No
Don’t
know
3. ...nerve gas agents (for example, sarin).
Yes
No
4. ...mustard gas or other blistering agents.
Yes
No
5. ...chlorine gas.
Yes
No
6. ...pesticides (for example, in flea collars, uniforms, or the environment).
Yes
No
7. ...government-issued DEET-containing insect repellents.
Yes
No
8. ...smoke or other air pollution.
Yes
No
9. ...diesel or other petrochemical fuel on my skin.
Yes
No
10. ...fumes or exhaust from heaters or generators, including heaters in tents.
Yes
No
11. ...depleted uranium in munitions.
Yes
No
12. ...burning trash or burning feces.
Yes
No
While I was deployed, I was exposed to:
7
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
Don’t
know
13. ...local food other than that provided by the Armed Forces.
Yes
No
14. ...poisoned food.
Yes
No
15. ...I was within 1 km of an exploding artillery shell.
Yes
No
Don’t
know
16. ...I was within 5 km of an exploding missile or mortar, or
attack by a rocket-propelled grenade (RPG).
Yes
No
Don’t
know
17. ...I was exposed to chemical or biological weapons.
Yes
No
Don’t
know
While I was deployed:
SECTION J: DEPLOYMENT CONCERNS
The statements below are about the amount of danger you felt you were exposed to while you were deployed. As
used in these statements, the term “unit” refers to those you lived and worked with on a daily basis during
deployment. Please describe how much you agree or disagree with each statement by circling the number that
best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. I thought I would never survive.
1
2
3
4
5
2. I felt safe.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
11. I was concerned about the effects of breathing bad air.
1
2
3
4
5
12. I worried about exposure to depleted uranium in munitions.
1
2
3
4
5
13. I feared that the protective gear I was given would not work.
1
2
3
4
5
14. I worried about getting an infectious disease.
1
2
3
4
5
15. I worried that I would be intentionally hurt by one of my own.
1
2
3
4
5
16. I was concerned that I would be attacked while on convoy or patrol.
1
2
3
4
5
17. I was concerned that a rocket or mortar would hit our living quarters.
1
2
3
4
5
18. I worried that others in my unit could not keep me safe.
1
2
3
4
5
3. I was extremely concerned that I would be exposed to nuclear,
biological, or chemical agents (NBC) agents.
4. I felt I was in great danger of being wounded (for example, losing a
limb).
5. I was concerned that my unit would be attacked.
6. I worried about the possibility of accidents (for example, “friendly”
fire or training injuries in my unit).
7. I was concerned that I would encounter an explosive device (for
example, a roadside bomb, mine, or booby trap).
8. I felt secure that I would be coming home after the war.
9. I was concerned that the medicine I was given to protect me from
illness would make me sick.
10. I felt that I would become sick from pesticides (for example, bug
spray) or other routinely used chemicals.
8
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
19. I spent a lot of time worrying about the bad things that could happen
to me.
1
2
3
4
5
20. I worried that someone I thought I could trust would turn against me.
1
2
3
4
5
21. I worried that I might be taken hostage.
1
2
3
4
5
SECTION K: TRAINING AND DEPLOYMENT PREPARATION
Below are several statements about how well prepared you were by the military for your deployment. As used
in these statements, the term “unit” refers to those you lived and worked with on a daily basis during
deployment. Please describe how much you agree or disagree with each statement by circling the number that
best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. I had the supplies and equipment needed to get my job done.
1
2
3
4
5
2. The equipment I was given functioned the way it was supposed to.
1
2
3
4
5
3. I received adequate training on how to use my equipment.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
6. I had enough gear to protect myself in case of an attack.
1
2
3
4
5
7. I received adequate training for the nature of the deployment I
experienced.
1
2
3
4
5
8. I was adequately prepared to deal with the region’s climate.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
12. I had a pretty good idea of how long my deployment would last.
1
2
3
4
5
13. I was accurately informed of what daily life would be like.
1
2
3
4
5
14. My military duties and assignments were what I expected.
1
2
3
4
5
15. My unit was prepared to operate as a team during deployment.
1
2
3
4
5
4. I knew how to treat animal bites, insect stings, or allergic reactions to
plants in the region.
5. I received adequate training on what to do in case of a nuclear,
biological, or chemical (NBC) attack.
9. I was accurately informed about what to expect from enemy
combatants.
10. I was trained by people who were knowledgeable and well-informed
about the topics they were covering.
11. I was informed about the role my unit was expected to play in the
deployment.
9
SECTION L: UNIT SUPPORT
The statements below are about your relationships with other military personnel while you were deployed. As
used in these statements, the term “unit” refers to those you lived and worked with on a daily basis during
deployment. Please describe how much you agree or disagree with each statement by circling the number that
best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. My unit was like family to me.
1
2
3
4
5
2. I felt a sense of camaraderie with other members of my unit.
1
2
3
4
5
3. Others in my unit understood me.
1
2
3
4
5
4. Most people in my unit were trustworthy.
1
2
3
4
5
5. I could go to most people in my unit for help when I had a personal
problem.
1
2
3
4
5
6. Other unit members appreciated my efforts.
1
2
3
4
5
7. Other unit members were there to “back me up” if things went wrong.
1
2
3
4
5
8. Unit leaders were interested in what I thought and how I felt about
things.
1
2
3
4
5
9. I was impressed by the quality of leadership in my unit.
1
2
3
4
5
10. Unit leaders made a real attempt to treat me as a person.
1
2
3
4
5
11. Unit leaders supported the decisions I made during deployment.
1
2
3
4
5
12. I felt like my efforts really counted to the military leadership.
1
2
3
4
5
13. My service was appreciated by the military leadership.
1
2
3
4
5
14. I was supported by the military leadership.
1
2
3
4
5
SECTION M: RELATIONSHIPS WITHIN UNIT
The next set of questions is again about your relationships with other military personnel while deployed. Please
describe how often you experienced each circumstance by circling the number that best fits your choice.
While I was deployed, military leaders or other service members:
Never
Once or
Many
Sometimes
twice
times
1. ...treated me in an overly critical way.
1
2
3
4
2. ...behaved in a way that was uncooperative when working with me.
1
2
3
4
3. ...treated me as if I had to work harder than others to prove myself.
1
2
3
4
4. ...questioned my abilities or commitment to perform my job effectively.
1
2
3
4
5. ...acted as though my mistakes were worse than others’.
1
2
3
4
6. ...tried to make my job more difficult to do.
1
2
3
4
7. ..."put me down" or treated me in a condescending way.
1
2
3
4
10
Never
While I was deployed, military leaders or other service members:
Once or
Many
Sometimes
twice
times
8. ...threatened my physical safety.
1
2
3
4
9. ...spread negative rumors about my sexual activities.
1
2
3
4
10. ...made crude and offensive sexual remarks directed at me, either publicly or
privately.
1
2
3
4
11. ...pressured me into unwanted sexual activity.
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
15. ...made unwanted attempts to have sex with me.
1
2
3
4
16. ...forced me to have sex.
1
2
3
4
12. ...offered me some sort of reward or special treatment to take part in sexual
behavior.
13. ...threatened me with some sort of retaliation for not being sexually cooperative
(for example, the threat of a negative review or physical violence).
14. ...made unwanted attempts to stroke or fondle me (for example, stroking my leg
or neck).
SECTION N: LIFE AND FAMILY CONCERNS
The following set of statements refers to concerns you may have had related to your life and family back home
while you were deployed. These questions do not ask if these events actually occurred, but only how concerned
you were that they might happen while you were deployed. Please describe how concerned you were by circling
the number that best fits your choice.
Not
Not at
A great
A little Moderately
applicable all
Deal
While I was deployed, I was concerned about:
1. …missing out on opportunities to start a career.
0
1
2
3
4
2. …missing out on a promotion at my job back home.
0
1
2
3
4
3. …damaging my career because I was deployed for a long time.
0
1
2
3
4
4. …losing touch with my co-workers or supervisors back home.
0
1
2
3
4
5. …being unable to financially support my family.
0
1
2
3
4
6. …harming my relationship with my spouse/significant other.
0
1
2
3
4
7. …being left by my spouse/significant other.
0
1
2
3
4
8. …missing out on my children’s growth and development.
0
1
2
3
4
9. …losing touch with my friends.
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
12. …my inability to directly manage or control family affairs.
0
1
2
3
4
13. …the care that my child(ren) or other dependents were receiving.
0
1
2
3
4
14. …the care that my pet(s) were receiving.
0
1
2
3
4
10. …missing important events at home such as birthdays, weddings,
funerals, graduations, etc.
11. …my inability to help my family or friends if they had some type of
problem.
11
Not
Not at
A great
A little Moderately
applicable all
Deal
While I was deployed, I was concerned about:
15. …being cheated on by my spouse or significant other.
0
1
2
3
4
16. …the safety and well-being of a loved one who was also deployed.
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
17. …sharing information with my family or other loved ones that would
cause them to worry.
18. …my family’s ability to manage their stress and worries about my
safety.
19. …my spouse or significant other’s ability to manage the household (for
example, chores, bills, home repairs, etc.).
20. …how my finances were being managed.
SECTION O: FAMILY EVENTS
The next set of statements refers to stressful family events that you may have experienced during your
deployment. Please circle “Yes” or “No” for each question below.
While I was deployed:
1. …I had serious problems getting in touch with a family member or other loved one.
Yes
No
2. …a family member or other loved one suffered a mental health crisis.
Yes
No
3. …a family member or other loved one had serious legal problems.
Yes
No
4. …a family member or other loved one was injured.
Yes
No
5. …a family member or other loved one was severely mistreated.
Yes
No
6. …a family member or other loved one passed away.
Yes
No
7. …my family had serious money problems.
Yes
No
8. …a spouse or significant other cheated on me.
Yes
No
9. …a spouse or significant other heard that I had cheated on him/her.
Yes
No
10. …my relationship with a spouse or significant other ended.
Yes
No
11. …I had a major conflict with a family member or other loved one.
Yes
No
12. …I stopped hearing from a family member or other loved one.
Yes
No
13. …my family or other loved ones had serious difficulty adjusting to my absence.
Yes
No
14. …my home was robbed or broken into.
Yes
No
15. …my money or belongings were stolen.
Yes
No
16. …a family member or other person I trusted stole or wasted my money.
Yes
No
17. …I learned that a loved one was doing things I disapproved of.
Yes
No
18. …a family member or other loved one was also deployed.
Yes
No
19. …a family member got into serious trouble at home, at school, or in the community.
Yes
No
12
SECTION P: SUPPORT FROM FAMILY/FRIENDS
The next set of statements refers to social support from family or friends during your deployment. Please
describe how much you agree or disagree with each statement by circling the number that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
During my deployment:
1. …I was carefully listened to by family members or friends.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
4. …I had problems that I could not discuss with family or friends.
1
2
3
4
5
5. …Among my friends or relatives, there was someone I could talk to
when I needed good advice.
1
2
3
4
5
6. …People at home just did not understand what I was going through.
1
2
3
4
5
7. …My friends and family respected my role in the Armed Forces.
1
2
3
4
5
8. …I had friends or relatives to look out for my family or other
dependents (including pets), or take care of my finances, property,
or belongings if needed.
1
2
3
4
5
9. …I was disappointed by how little communication I got from home.
1
2
3
4
5
10. …I was disappointed by how little support I got from home.
1
2
3
4
5
11. …There were people at home who cared about me.
1
2
3
4
5
12. …I had friends or family members I could talk to about my
deployment experiences.
1
2
3
4
5
2. …I had family members or friends back home who were proud of my
service to my country.
3. …Among my friends or relatives, there was someone who made me
feel better when I was feeling down.
SECTION Q: POSTDEPLOYMENT REINTEGRATION
You have completed the questions about your deployment. The next set of statements relates to experiences that
you may have had in the process of readjusting/reintegrating into life at home after deployment. Please
describe how much you agree or disagree with each statement as it reflects your experiences IN THE FIRST
THREE MONTHS AFTER YOU RETURNED FROM DEPLOYMENT by circling the number that best fits
your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. The transition back from deployment went smoothly.
1
2
3
4
5
2. I was frustrated by people asking me questions about my deployment.
1
2
3
4
5
3. Finding a job or returning to work or school was difficult for me.
1
2
3
4
5
4. I was happy at work or school.
1
2
3
4
5
5. I had trouble getting along with others at work or school.
1
2
3
4
5
6. Other people’s complaints about their daily lives irritated me.
1
2
3
4
5
7. I felt more comfortable talking to my military buddies than my friends
or family.
1
2
3
4
5
13
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
8. I had trouble dealing with people who reminded me of the enemy.
1
2
3
4
5
9. I didn’t feel needed by friends, family, or coworkers anymore.
1
2
3
4
5
10. I felt like I was in the way around my friends and family.
1
2
3
4
5
11. I no longer fit in with my friends and family.
1
2
3
4
5
12. I had trouble relaxing around friends and family.
1
2
3
4
5
13. I enjoyed doing the things I used to do.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
16. People bothered or annoyed me more than they used to.
1
2
3
4
5
17. People voiced opinions about the deployment that made me angry.
1
2
3
4
5
18. I found it hard to be around old friends.
1
2
3
4
5
19. I had an easy time making new friends.
1
2
3
4
5
20. Someone I relied on for support was no longer around.
1
2
3
4
5
14. I spent a lot of time watching TV shows, listening to radio programs,
or reading articles about the war.
15. It was hard for me to stop thinking about things that happened during
the deployment.
SECTION R: POSTDEPLOYMENT SUPPORT
The next set of statements refers to social support AFTER DEPLOYMENT. Please describe how much you
agree or disagree with each statement by circling the number that best fits your choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. The reception I received from my family made me feel appreciated
for my efforts.
2. The reception I received from members of my community made me
feel appreciated for my efforts.
1
2
3
4
5
1
2
3
4
5
3. The American people made me feel at home when I returned.
1
2
3
4
5
4. When I returned, people made me feel proud to have served my
country in the Armed Forces.
1
2
3
4
5
5. I am carefully listened to by family members or friends.
1
2
3
4
5
6. Among my friends or relatives, there is someone who makes me feel
better when I am feeling down.
1
2
3
4
5
7. I have problems that I can't discuss with family or friends.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
8. Among my friends or relatives, there is someone I go to when I need
good advice.
9. People at home just don't understand what I have been through
while in the Armed Forces.
10. There are people to whom I can talk about my deployment
experiences.
14
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
11. The people I work with respect the fact that I served my country.
1
2
3
4
5
12. My supervisor would understand if I needed time off to take care of
personal matters.
1
2
3
4
5
13. My friends or relatives would lend me money if I needed it.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
14. My friends or relatives would help me move my belongings if I
needed to.
15. If I were unable to attend to daily chores, there is someone who
would help me with those tasks.
16. When I am ill, friends or family members help out until I am well.
SECTION S: POSTDEPLOYMENT FAMILY EXPERIENCES
The sentences below refer to family experiences for military personnel who are CURRENTLY married or
living with other family members. Please describe how much you agree or disagree with each statement by
circling the number that best fits your choice. If you spend time in more than one family setting, please answer
these questions about the family in which you spend the greatest amount of time.
PLEASE SKIP TO SECTION U IF YOU ARE NOT MARRIED OR LIVING WITH OTHER FAMILY
MEMBERS.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
1. People in my family do things together.
1
2
3
4
5
2. Family members get on each other’s nerves.
1
2
3
4
5
3. Family members feel uncomfortable with each other.
1
2
3
4
5
4. Family members are there for each other during difficult times.
1
2
3
4
5
5. Family members feel very close to each other.
1
2
3
4
5
6. Family members avoid each other.
1
2
3
4
5
7. When problems arise, family members compromise.
1
2
3
4
5
8. Family members are afraid to say what is on their minds.
1
2
3
4
5
9. There is fighting among family members.
1
2
3
4
5
10. Family members yell when they are angry with each other.
1
2
3
4
5
11. Family members discuss their personal problems with each other.
1
2
3
4
5
12. Family members share household responsibilities.
1
2
3
4
5
13. Family members are affectionate with each other.
1
2
3
4
5
14. Family members insult or swear at each other.
1
2
3
4
5
15. Family members are critical of each other.
1
2
3
4
5
15
SECTION T: POSTDEPLOYMENT LIFE EVENTS
The next statements refer to events you may have experienced SINCE RETURNING FROM YOUR
DEPLOYMENT. These questions are similar to the questions you’ve answered previously about events
before your deployment. Please circle “Yes” or “No” for each question below.
Since returning home:
1. ...I have experienced a natural disaster (for example, a hurricane), a fire, or an accident in which I
Yes
or someone close to me was hurt or had serious property damage.
No
2. ...I have been exposed to a toxic substance (such as dangerous chemicals or radiation).
Yes
No
3. ...someone close to me has experienced serious physical or mental health problems.
Yes
No
4. ...someone close to me has died.
Yes
No
5. ...a close family member or friend has experienced a serious drug or alcohol problem.
Yes
No
6. ...I have gone through a divorce or been left by a significant other.
Yes
No
7. ...I have witnessed someone being seriously assaulted or killed.
Yes
No
8. ...I have been robbed or had my home broken into.
Yes
No
9. ...I have lost my job or been demoted.
Yes
No
10. ...I have been emotionally mistreated by a family member or other loved one (for example,
ignored or repeatedly told I was no good).
Yes
No
11. ...I have experienced serious financial problems.
Yes
No
12. ...I have experienced serious physical or mental health problems.
Yes
No
13. ...I have experienced stressful legal problems (for example, being sued, suing someone else, or
being in a custody battle).
Yes
No
14. ...I have been unemployed and seeking employment for at least 3 months.
Yes
No
15. ...I have had problems getting access to adequate healthcare.
Yes
No
16. ...I have been seriously physically injured by another person (for example, hit or beaten up).
Yes
No
17. ...I have experienced unwanted sexual activity as a result of force, threat of harm, or manipulation.
Yes
No
SECTION U: FEELING AND EMOTIONS
Next is a set of statements about feelings you may or may not have experienced IN THE LAST THREE
MONTHS. Please read each statement and indicate the extent to which you agree or disagree with each
statement by circling the number corresponding to your response choice.
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
In the last three months...
1. ...I have felt sad.
1
2
3
4
5
2.
...I have felt discouraged about the future.
1
2
3
4
5
3.
...I have felt like a failure.
1
2
3
4
5
4. ...I haven’t gotten as much satisfaction out of things as I used to.
1
2
3
4
5
5.
1
2
3
4
5
...I have been disappointed in myself.
16
Neither
Strongly Somewhat
Somewhat Strongly
agree nor
disagree disagree
agree
agree
disagree
In the last three months...
6.
...I have been critical of myself for my weaknesses or mistakes.
1
2
3
4
5
7.
...I have had thoughts about killing myself.
1
2
3
4
5
8. ...I have been unable to relax.
1
2
3
4
5
9.
1
2
3
4
5
10. ...I have felt terrified.
1
2
3
4
5
11. ...I have felt nervous.
1
2
3
4
5
12. ...I have had a fear of losing control.
1
2
3
4
5
13. ...I have had a fear of dying.
1
2
3
4
5
14. ...I have felt scared.
1
2
3
4
5
...I have had a fear of the worst happening.
SECTION V: POST-DEPLOYMENT DISTRESS
The following statements refer to feelings you may have had since returning from your deployment. Please
think about the event or events that were most disturbing to you while you were deployed and respond to the
statements about experiences or feelings you have had IN THE LAST THREE MONTHS. Circle the number
that best fits your choice.
Not at
all
A little
bit
Moderately
1. ...repeated, disturbing memories of my military experiences.
1
2
3
4
5
2. ...repeated, disturbing dreams of my military experiences.
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
5. ...trouble remembering important parts of my military experiences.
1
2
3
4
5
6. ...loss of interest in activities that I used to enjoy.
1
2
3
4
5
7. ...feeling distant or cut off from other people.
1
2
3
4
5
8. ...feeling emotionally numb, or being unable to have loving feelings
for those close to me.
1
2
3
4
5
9. ...feeling as if my future will somehow be cut short.
1
2
3
4
5
10. ...trouble falling or staying asleep.
1
2
3
4
5
11. ...feeling irritable or having angry outbursts.
1
2
3
4
5
12. ...having difficulty concentrating.
1
2
3
4
5
13. ...being “super alert,” or watchful or on guard.
1
2
3
4
5
14. ...feeling jumpy or easily startled.
1
2
3
4
5
15. ...having physical reactions when something reminds me of my
military experiences.
1
2
3
4
5
In the last three months I have been bothered by...
3. ...suddenly acting or feeling as if my military experiences were
happening again.
4. ...feeling very upset when something happened that reminded me of
my military experiences.
17
Quite a
Extremely
bit
In the past three months, I have tried to:
16. ...avoid thinking about my military experiences, or avoid having
feelings about them.
17. ...avoid activities or situations because they reminded me of my
military experiences.
Not at
all
A little
bit
Moderately
Quite a
Extremely
bit
1
2
3
4
5
1
2
3
4
5
SECTION W: CURRENT HEALTH
The following questions ask about your current health. Please circle the response corresponding to the most
appropriate option.
1. In general, would you say your health is:
Excellent
2. Does your health now limit you in moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling or playing golf?
3. Does your health now limit you in climbing several flights of stairs?
Very
good
Good
Fair
Poor
No, not
limited
at all
No, not
limited
at all
Yes,
limited
a little
Yes,
limited
a little
Yes,
limited
a lot
Yes,
limited
a lot
4. In the past four weeks, have you accomplished less than you would like as a result of your
Yes
No
physical health?
5. In the past four weeks, have you been limited in your work or other activities as a result of
Yes
No
your physical health?
6. In the past four weeks, have you accomplished less than you would like as a result of any
Yes
No
emotional problems (such as feeling depressed or anxious)?
7. In the past four weeks, have you not done work or other activities as carefully as usual as a
Yes
No
result of any emotional problems?
8. During the past four weeks, how much did pain interfere with your
A
Quite
Moderately
Extremely
a bit
normal work (including both work outside the home and housework)? little bit
How much of the time during the past four weeks…
1.
…have you felt calm and peaceful?
2.
…did you have a lot of energy?
A little
Some of the
of the
time
time
A little
Some of the
of the
time
time
A good
bit of
the time
A good
bit of
the time
All of
the
time
All of
Most of
the
the time
time
Most of
the time
How much of the time during the past four weeks…
3.
…have you felt downhearted and blue?
4.
…has your physical health or emotional problems interfered with
your social activities (like visiting with friends, relatives, etc.?)
A little
A good
All of
Some of the
Most of
of the
bit of
the
time
the time
time
the time
time
A little
Some of the Most of the All of the
of the
time
time
time
time
SECTION X: ALCOHOL USE
The following questions relate to your use of alcohol. Please circle the response corresponding to the most
appropriate option.
No
Yes, at some Yes, in the
Yes, before I
time after
last 3
was deployed
deployment months
1.
Have you felt you ought to cut down on drinking?
1
2
3
4
2.
Have people criticized your drinking?
1
2
3
4
18
No
Yes, at some Yes, in the
Yes, before I
time after
last 3
was deployed
deployment months
3.
Have you felt bad or guilty about your drinking?
1
2
3
4
4.
Have you had a drink first thing in the morning to steady
your nerves or get rid of a hangover (an “eye-opener”)?
1
2
3
4
5.
In the past three months how often have you had a drink
containing alcohol?
Never
4 or more
Monthly or 2 to 3 times 2 to 3 times
times a
less
a month
a week
week
6.
In the past three months, how many drinks containing
alcohol have you had on a typical day when you were
drinking?
None
1 or 2
3 or 4
5 or 6
7 or 9
More
than 5
years
SECTION Y: HEALTH-CARE USE
The next statements refer to your use of health care SINCE RETURNING FROM YOUR MOST RECENT
DEPLOYMENT TO OEF/OIF. Please circle “Yes” or “No” for each question below.
Since returning home:
1. Have you had a physical health problem that required health care?
Yes
No
2. Have you had an emotional problem that required health care?
Yes
No
3. Have you gotten any medical care for yourself? For example, hospital stays, doctor’s visits, urgent
care, routine exams, medical tests, or shots?
Yes
No
3a. If yes, did you go to a Department of Veterans Affairs (VA) health-care facility for any of this care?
Yes
No
4. Have you seen a professional for help with an emotional problem? These professionals could be
psychologists, therapists, counselors, or psychiatrists, and could include groups led by professional
counselors and visits for medication for emotional problems?
Yes
No
4a. If yes, did you go to a Department of Veterans Affairs (VA) health-care facility for any of this care?
Yes
No
SECTION Z: ADDITIONAL SURVEY INFORMATION
Please check the appropriate response or fill in the required information.
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. What is the highest level of education you have attained?
___ 8th grade or less
___ Some high school
___ High school graduate
___ Vocational or technical training
___ Some college
___ Four-year college graduate
___ Some graduate or professional school
___ Graduate or professional degree
19
6. What is your current marital status?
___ Married
___ Living as a couple
___ Separated
___ Divorced
___ Widowed
___ Single/Never married
7. Which of the following categories best describes your 2006 household income before taxes?
___ $15,000 or less
___ $50,001 to $75,000
___ $15,001 to $25,000
___ $75,001 to $100,000
___ $25,001 to $35,000
___ Over $100,000
___ $35,001 to $50,000
8. Are you currently serving in the military either on active duty or with the National Guard or Reserves?
___ Yes
___ No
8a. (If Yes) Are you currently:
___ Regular active duty
___ National Guard
___ Reserves
9. Have you ever or are you currently applying for service-connected disability status?
___ Yes
___ No
9a. (If yes, in past) Did you receive service-connected disability status?
___ Yes
___ No
10. During what time period was your most recent deployment to Iraq or Afghanistan?
From ____/____/____ (month/day/year)
To ____/____/____ (month/day/year)
11. Was this most recent deployment in support of:
___ OEF (Operation Enduring Freedom)
___ OIF (Operation Iraqi Freedom)
12. When you were deployed, were you:
___ Regular active duty
___ National Guard
___ Reserves
13. What was your branch of the military when you were deployed?
Marines____ Army____ Navy____
Air Force____ Coast Guard ____
14. What was your military rank when you were deployed (e.g., E-5, O-6)? _____________
15. What was your primary military occupation (MOS, SSI, Rating or NEC, NOBC, or AFSC) when you
were deployed? _____________
20
16. Please briefly describe what duties your unit performed (e.g. transportation, moving equipment from
ports to front lines).
________________________________________________________________________________________
________________________________________________________________________________________
17. Where were you stationed?
________________________________________________________________________________________
________________________________________________________________________________________
18. What was your marital status when you deployed?
___ Married
___ Divorced
___ Living as a couple
___ Widowed
___ Separated
___ Single/Never married
19. Did you have any children when you deployed?
___ Yes
___ No
20. Have you had children since you deployed?
___ Yes
___ No
21. IF YES TO EITHER 18 OR 19: How many children do you have and what are their ages?
____________________________________________
22. Do you think that you have in the past or are currently suffering from deployment-related illnesses?
___ No, never
___ Yes, in the past
___ Yes, currently
Please take a minute to go back through the survey and make sure you
haven’t skipped any pages.
Thank you for your participation!
21
| File Type | application/pdf |
| File Title | The Gulf War Experiences Project |
| Author | VHABOSEVANSC |
| File Modified | 2008-08-28 |
| File Created | 2008-08-28 |