Download:
pdf |
pdf1892191461
Consent Form
•
What is the study about?
You are being asked to be a volunteer in a research study called "The Millennium Cohort Study" conducted by the US
Department of Defense (DoD). This study will follow the long-term health of military personnel during and after their
military service. The purpose is to assess the health outcomes of military deployment, military occupations, and general
military service. You have been scientifically selected to represent your service branch, gender, service type, military
occupation, and age group from among the over two million military personnel serving as of October 2009 in the regular
Active Duty, Reserve, and National Guard forces. It is very important that you participate because no one else can
provide the data your country and fellow service men and women need from you.
•
What will participation involve?
You are being asked to do the following:
Complete the attached survey today. You are also being asked to complete 4 follow-up surveys over 12 years, with one
survey to complete every three years. Filling out the survey will take about 30 minutes each time you complete it. The
surveys contain questions on a broad range of health topics, including medical conditions, health behaviors, and
exposures that may affect your health. We will connect your survey data with other data, medical records, or biomarkers
collected and maintained by the Department of Defense, or federal and state agencies, on your military
service, deployments, and medical care. Additionally, you may be asked to participate in other sub-studies and if you so
choose may involve a variety of tests including neurocognitive testing and blood samples.
You will be contacted semi-annually to verify your contact information. In addition, there is a 3% random chance that you
will be contacted by telephone for focus group testing. You are one of approximately 200,000 volunteers who are being
asked to participate in this very important study.
•
What risks are involved in the study?
The data collection procedures are not expected to involve any risk or discomfort to you. The only risks to you are those
associated with the inappropriate disclosure of data you provide. However, this research group has collected similar
information from hundreds of studies over many years without any cases of inappropriate disclosure.
•
How will your data be protected against those risks?
All surveys will be kept in locked files. When your data are entered into computer files for analysis, your answers will be
identified only by a special study identification number known to you and research team members. This number is
located on the barcode of your study envelope and survey. Your social security number and any other personal
identification information will be removed from your survey and data file upon return to the researchers. Even if someone
outside the research team broke into the files, it would be impossible for them to identify your data. To minimize the risk
of anyone breaking into the data files, those files will be maintained on DoD computers protected by all the measures
required by DoD computer security regulations. All members of the research team with access to data files will be
trained in DoD computer security procedures specifically designed to protect sensitive data. Reports of the study findings
will contain only group data, so that no individual study participant can be identified. Similar procedures have been used
to protect data in previous studies conducted within this research center.
According to the DoD Policy "Interim Regulations to Improve Privacy Protections for DoD Medical Records" dated
October 31, 2000, the information you provide is for research purposes only and may not be disclosed except for
specifically authorized purposes or with the consent of the individual about whom the information pertains. Uses and
disclosures of this information shall comply with provisions of the Privacy Act and implementing regulations.
continued on page 2...
THIS COPY IS FOR YOUR PERSONAL RECORDS. PLEASE REMEMBER TO SIGN AND DATE THE CONSENT FORM
ATTACHED TO YOUR QUESTIONNAIRE BOOKLET.
Page 1
8671191463
continued from page 1.....
How is your information protected if you complete the survey using the Internet web site option?
•
All information collected through the Internet survey option is done by using Secure Sockets Layer (SSL) data
transmission lines. SSL encrypts, or scrambles, all questionnaire data sent over the Internet. Information will only be
understandable when it reaches the investigator database. The same methods of protection listed above will then be
followed to further protect your information.
What are the benefits of participating in the study?
•
While your participation in this study may not directly benefit you, your participation will help define health care policy
for future generations of military personnel and guide prevention and treatment programs for years to come.
Will you be provided medical care based on your responses?
No. This is a population-based study and data collected will not be used to make decisions about treatment that any
individual should receive. If you feel that you might need medical care or counseling you should make contact with the
appropriate health care personnel.
•
Do you have to participate?
•
No, you do not! Your participation must be completely voluntary. If you decide to participate, you can stop at any time you
wish or skip any question you choose. If you choose not to participate or to discontinue your participation, you will not lose
any benefit to which you are otherwise entitled. You may change your mind and revoke your permission to further collect
or use your health information at any time. If you revoke your permission, no new health information about you will be
gathered after that date. However, unless specified otherwise, information that has already been gathered may still be
used for analyses. To end participation, contact the principal investigator at MilCohortInfo@med.navy.mil or (888)
942-5222.
Your participation may also be ended by the investigators. While this is not anticipated, available funding or other logistical
considerations could conceivably result in the study not running its full course.
Who can provide additional information if you need it?
•
Questions about the research (science) aspects of this study should be directed to the principal investigator of the
Millennium Cohort Study at MilCohortInfo@med.navy.mil or (888) 942-5222. You may also refer to the web site at
www.MillenniumCohort.org for more information. Questions about the ethical aspects of this study, your rights as a
volunteer, or any problem related to the protection of research volunteers should be directed to Christopher G. Blood, JD,
MA, Chairperson, Institutional Review Board, Naval Health Research Center, at NHRC-IRB@med.navy.mil or (619)
553-8386.
Where can you find your records if you wish to review them?
The principal investigator will be responsible for storing the consent form and other research records related to this study.
The records will be stored at the DoD Center for Deployment Health Research, Naval Health Research Center, 140
Sylvester Road, San Diego, CA 92106-3521. You can review your surveys until the study ends by contacting the principal
investigator at MilCohortInfo@med.navy.mil or (888) 942-5222.
•
Voluntary Consent
I consent to participate in the study described above. My consent is completely voluntary and is based solely
on the information provided in this consent form.
Volunteer's signature
Date (mm/dd/yy)
Volunteer's printed name (first, middle initial, last)
Page 2
9310525207
Consent
For office use only
You may also complete this questionnaire online at
www.MillenniumCohort.org
MARKING INSTRUCTIONS
• Use BLACK or BLUE ink.
• Shade circles like this:
• Mistakes must be crossed out with an "X".
• Print in CAPITAL LETTERS and avoid contact with the edge of the box. EXAMPLE:
A B C D E F G H
I
J K L M N O P Q R S T U V W X Y Z
• Answer every question to the best of your ability.
• It will take approximately 30 minutes to complete the questionnaire.
1. What is your current mailing address?
Address Line 1:
Address Line 2
(optional):
City (or FPO/APO):
State/Province/Region
(or AA/AE/AP):
ZIP/Postal Code:
Country:
2. Please provide your daytime phone number:
3. Please provide your email address:
If any of your contact information changes, please log on to www.MillenniumCohort.org
or call our toll-free number at (888) 942-5222 to provide an update.
4. What year were you born?
1
9
M
6. What is today's date?
5. What are the last four digits of your Social Security
number?
M
D D
/
/
Y
Y
Y
2
0
0
Page 3
Y
0227525205
7. What is your current marital status?
Choose the single best answer.
9. Are you a twin? (or triplet or one of a multiple birth set)
No
Single, never married
Yes
Now married
Do not know
Separated
Divorced
10. How tall are you? For example, a person who is 5'8"
tall would write 5 feet 08 inches.
Widowed
8. What is the highest level of education that you
have completed?
Choose the single best answer.
feet
inches
Less than high school completion/diploma
High school degree/GED/or equivalent
Some college, no degree
11. What is your current weight?
pounds
12. How much did you weigh a year ago?
pounds
Associate's degree
Bachelor's degree
Master's, doctorate, or professional degree
If you are FEMALE, please continue to question 13
If you are MALE, please skip to question 14 on page 5
13. FOR WOMEN ONLY:
a. Have you had at least one menstrual period in the past 12 months?
No
Yes
b. If NO: what is the reason that you have not had a menstrual period in the past 12 months?
Mark all that apply.
pregnancy and/or breast feeding
hysterectomy
contraception or hormone therapy
other
menopause
unknown
please specify
No
c. During the week before your period starts, do you have a serious problem
with your mood - like depression, anxiety, irritability, anger, or mood swings?
d. If YES: do these problems go away by the end of your period?
e. Have you given birth within the last 3 years?
f.
Have you had a miscarriage within the last 3 years?
g. During the last 3 years, have you tried and been unable to become pregnant?
Page 4
Yes
Does
not apply
7306525200
14. Has your doctor or other health professional ever told you that you have
any of the following conditions?
If YES, in what
year were you
first diagnosed?
Mark here if you
were ever
hospitalized for
the condition
a. Hypertension (high blood pressure)
No
Yes
Hospitalized
b. Coronary heart disease
No
Yes
Hospitalized
c. Heart attack
No
Yes
Hospitalized
d. Angina (chest pain)
No
Yes
Hospitalized
No
Yes
Hospitalized
No
Yes
Hospitalized
g. Chronic bronchitis
No
Yes
Hospitalized
h. Emphysema
No
Yes
Hospitalized
i.
Asthma
No
Yes
Hospitalized
j.
Kidney failure requiring dialysis
No
Yes
Hospitalized
k. Bladder infection
No
Yes
Hospitalized
l.
No
Yes
Hospitalized
m. Diabetes or sugar diabetes
No
Yes
Hospitalized
n. Gallstones
No
Yes
Hospitalized
o. Hepatitis B
No
Yes
Hospitalized
p. Hepatitis C
No
Yes
Hospitalized
q. Any other hepatitis
No
Yes
Hospitalized
r.
Cirrhosis
No
Yes
Hospitalized
s. Fibromyalgia
No
Yes
Hospitalized
t.
No
Yes
Hospitalized
No
Yes
Hospitalized
e. Any other heart condition
please specify
f.
Sinusitis
Pancreatitis
Rheumatoid arthritis
u. Lupus
Question 14 continued on page 6...
Page 5
1517525208
Question 14 continued...
Has your doctor or other health professional ever told you that you have
any of the following conditions?
If YES, in what
year were you
first diagnosed?
Mark here if you
were ever
hospitalized for
the condition
v. Multiple sclerosis
No
Yes
Hospitalized
w. Crohn's disease
No
Yes
Hospitalized
x. Stomach, duodenal, or peptic ulcer
No
Yes
Hospitalized
y. Ulcerative colitis or proctitis
No
Yes
Hospitalized
z. Significant hearing loss
No
Yes
Hospitalized
aa. Significant vision loss even with glasses or contact lenses
No
Yes
Hospitalized
bb. Migraine headaches
No
Yes
Hospitalized
cc. Stroke
No
Yes
Hospitalized
dd. Neuropathy-caused reduced sensation in hands or feet
No
Yes
Hospitalized
ee. Seizures
No
Yes
Hospitalized
ff. Sleep apnea
No
Yes
Hospitalized
gg. Anemia
No
Yes
Hospitalized
hh. Thyroid condition other than cancer
No
Yes
Hospitalized
No
Yes
Hospitalized
jj. Chronic fatigue syndrome
No
Yes
Hospitalized
kk. Depression
No
Yes
Hospitalized
ll. Schizophrenia or psychosis
No
Yes
Hospitalized
No
Yes
Hospitalized
No
Yes
Hospitalized
No
Yes
Hospitalized
ii. Cancer
please specify
mm. Manic-depressive disorder
nn. Posttraumatic stress disorder
oo. Other
please specify
Page 6
5610525206
15. During the last 12 months, have you had persistent or recurring problems with any of the following?
a. Severe headache
No
Yes
k. Night sweats
No
Yes
b. Diarrhea
No
Yes
l.
No
Yes
c. Rash or skin ulcer
No
Yes
m. Unusual muscle pains
No
Yes
d. Sore throat
No
Yes
n. Shortness of breath
No
Yes
e. Frequent bladder infections
No
Yes
o. Trouble sleeping
No
Yes
f.
No
Yes
p. Unusual fatigue
No
Yes
g. Fever
No
Yes
q. Forgetfulness
No
Yes
h. Sudden unexplained hair loss
No
Yes
r.
No
Yes
i.
Earlobe pain
No
Yes
s. Other
No
Yes
j.
Sleepy all the time
No
Yes
Cough
Chest pain
Confusion
please specify
16. Over the past 12 months, approximately how many days were you hospitalized because of illness or injury?
(exclude hospitalization for pregnancy and childbirth)
None
1 day
2-5 days
6-10 days
11-15 days
16-20 days
21 days or more
17. Over the past 12 months, approximately how many days were you unable to work or perform your usual activities
because of illness or injury? (exclude lost time for pregnancy and childbirth)
None
1 day
2-5 days
6-10 days
11-15 days
16-20 days
21 days or more
18. During the last 4 weeks, how much have you been bothered by any of the following problems?
Not bothered
a. Stomach pain
b. Back pain
c. Pain in your arms, legs, or joints (knees, hips, etc)
d. Pain or problems during sexual intercourse
e. Headaches
f.
Chest pain
g. Dizziness
h. Fainting spells
i.
Feeling your heart pound or race
j.
Shortness of breath
k. Constipation, loose bowels, or diarrhea
l.
Nausea, gas, or indigestion
m. Women only: menstrual cramps or other problems with
your periods
Page 7
Bothered
a little
Bothered
a lot
1393525200
19. Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all
Several
days
More than
half the
days
Nearly
every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f.
Feeling bad about yourself, or that you are a failure or have
let yourself or your family down
g. Trouble concentrating on things, such as reading the newspaper
or watching television
h. Moving or speaking so slowly that other people could have noticed,
or the opposite - being so fidgety or restless that you have been
moving around a lot more than usual
i.
Thoughts that you would be better off dead or of hurting
yourself in some way
If you have been bothered by any of the items listed above, you may want to
seek help from a health professional in your area.
20.
a. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic?
No
Yes
b. Has this ever happened to you before?
No
Yes
c. Do some of these attacks come suddenly out of the blue - that is, in
situations where you don't expect to be nervous or uncomfortable?
No
Yes
d. Do these attacks bother you a lot, or are you worried about having another attack?
No
Yes
a. Were you short of breath?
No
Yes
b. Did your heart race, pound, or skip?
No
Yes
c. Did you have chest pain or pressure?
No
Yes
d. Did you sweat?
No
Yes
e. Did you feel as if you were choking?
No
Yes
f.
No
Yes
g. Did you have nausea or an upset stomach, or the feeling that you were
going to have diarrhea?
No
Yes
h. Did you feel dizzy, unsteady, or faint?
No
Yes
i.
Did you have tingling or numbness in parts of your body?
No
Yes
j.
Did you tremble or shake?
No
Yes
No
Yes
If you marked NO, please skip to question 22 on page 9
21. Think about your last bad anxiety attack.
Did you have hot flashes or chills?
k. Were you afraid you were dying?
Page 8
2772525202
22. Over the last 4 weeks, how often have you been bothered by any of the following problems?
Not
at all
More
than half
the days
Several
days
a. Feeling nervous, anxious, on edge, or worrying a lot
about different things
If you marked NOT AT ALL, skip to question 23
b. Feeling restless so that it is hard to sit still
c. Getting tired very easily
d. Muscle tension, aches, or soreness
e. Trouble falling asleep or staying asleep
f.
Trouble concentrating on things, such as reading a book or
watching TV
g. Becoming easily annoyed or irritable
23. On an average day, how many 8-12 oz beverages containing caffeine do you drink (such as coffee, tea, soda)?
None
1-2 per day
3-5 per day
6-10 per day
11 or more per day
24. About how many times each week do you eat from a fast food restaurant (such as hamburgers, tacos, or pizza)?
None
Once a week
2-3 times/week
4-7 times/week
8-14 times/week
25. a. Do you often feel that you can't control what or how much you eat?
15 or more times/week
No
Yes
b. Do you often eat, within any 2 hour period, what most people would regard as
an unusually large amount of food?
No
Yes
c. If you marked YES to either of the above, has this been as often, on
average, as twice a week for the LAST 3 MONTHS?
No
Yes
a. Made yourself vomit?
No
Yes
b. Took more than twice the recommended dose of laxatives?
No
Yes
c. Fasted - not eaten anything at all for at least 24 hours?
No
Yes
d. Exercised for more than an hour specifically to avoid gaining weight after binge eating?
No
Yes
e. If you marked YES to any of these ways of avoiding gaining weight, were any as
often, on average, as twice a week?
No
Yes
26. In the last 3 months, have you done any of the following in order to avoid gaining weight?
Page 9
0902525205
27. In the last 4 weeks, how much have you been bothered by any of the following problems?
Not
bothered
Bothered
a little
Bothered
a lot
a. Worrying about your health
b. Your weight or how you look
c. Little or no sexual desire or pleasure during sex
d. Difficulties with husband/wife, partner/lover, or boyfriend/girlfriend
e. The stress of taking care of children, parents, or other family members
f.
Stress at work outside of the home or at school
g. Financial problems or worries
h. Having no one to turn to when you have a problem
i.
Something bad that happened recently
j.
Thinking or dreaming about something terrible that happened to you in
the past - like your house being destroyed, a severe accident, being
hit or assaulted, or being forced into a sexual act
28. In the last year, have you been hit, slapped, kicked, or otherwise physically hurt
by someone, or has anyone forced you to have an unwanted sexual act?
No
Yes
29. Are you currently taking any medicine for anxiety, depression, or stress?
No
Yes
30. Over the past month, how many hours of sleep did you get in an average
24-hour period?
hours
31. In the past month have you experienced...?
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
a. Repeated, disturbing memories of stressful
experiences from the past
b. Repeated, disturbing dreams of stressful
experiences from the past
c. Suddenly acting or feeling as if stressful
experiences were happening again
d. Feeling very upset when something happened that
reminds you of stressful experiences from the past
e. Trouble remembering important parts of stressful
experiences from the past
f.
Loss of interest in activities that you used to enjoy
g. Feeling distant or cut off from other people
h. Feeling emotionally numb, or being unable to have
loving feelings for those close to you
Question 31 continued on page 11...
Page 10
0307525204
Question 31 continued...
In the past month have you experienced...?
i.
Feeling as if your future will somehow be cut short
j.
Trouble falling asleep or staying asleep
Not at
all
A little
bit
Moderately
Quite
a bit
Extremely
k. Feeling irritable or having angry outbursts
l.
Difficulty concentrating
m. Feeling "super-alert" or watchful or on guard
n. Feeling jumpy or easily startled
o. Physical reactions when something reminds you of
stressful experiences from the past
p. Efforts to avoid thinking about your stressful
experiences from the past or avoid having feelings
about them
q. Efforts to avoid activities or situations because they
remind you of stressful experiences from the past
32. In general, would you say your health is: (Please select only one)
Excellent
Very good
Good
Fair
Poor
33. In a typical week, how much time do you spend participating in...
(Please mark both your typical "days per week" and "minutes per day" doing these activities)
None
a. STRENGTH TRAINING or work that strengthens your
muscles? (such as lifting/pushing/pulling weights)
Days per week
b. VIGOROUS exercise or work that causes heavy
sweating or large increases in breathing or heart
rate? (such as running, active sports, marching, biking)
c. MODERATE or LIGHT exercise or work that causes
light sweating or slight increases in breathing or
heart rate? (such as walking, cleaning, slow jogging)
Minutes per day
Cannot physically do
None
Days per week
Minutes per day
Cannot physically do
None
Days per week
Page 11
Minutes per day
Cannot physically do
6385525206
34. Choose the single best description of your USUAL daily activities.
You sit during the day and do not walk much.
You stand or walk a lot during the day, but do not carry or lift things often.
You lift or carry light loads, or climb stairs or hills often.
You do heavy work or carry heavy loads often.
35. On a typical day, how much time do you spend sitting and watching TV or videos or using a computer?
hours per day
36. The following questions are about activities you might do during a typical day. Does your health now limit you
in these activities? If so, how much?
No, not limited
Yes, limited
Yes, limited
at all
a little
a lot
a. Vigorous activities, such as running, lifting heavy objects, or
participating in strenuous sports?
b. Moderate activities, such as moving a table, pushing a vacuum
cleaner, bowling, or playing golf?
c. Lifting or carrying groceries?
d. Climbing several flights of stairs?
e. Climbing one flight of stairs?
f. Bending, kneeling, or stooping?
g. Walking more than a mile?
h. Walking several blocks?
i. Walking one block?
j. Bathing or dressing yourself?
37. During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of your physical health?
No,
Yes,
Yes,
Yes,
none of
a little of
some of
most of
the time
the time
the time
the time
a. Cut down the amount of time you spent on work or
other activities
b. Accomplished less than you would like
c. Were limited in the kind of work or other activities
d. Had difficulty performing the work or other activities
(for example, it took extra effort)
Page 12
Yes,
all of
the time
2297525204
38. During the past 4 weeks, have you had any of the following problems with your work or other regular daily
activities as a result of any emotional problems (such as feeling depressed or anxious)?
No,
none of
the time
Yes,
a little of
the time
Yes,
some of
the time
Yes,
most of
the time
Yes,
all of
the time
a. Cut down the amount of time you spent on work or
other activities
b. Accomplished less than you would like
c. Didn't do work or other activities as carefully as usual
39. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your
normal social activities with family, friends, neighbors, or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
40. During the past 4 weeks, how much bodily pain have you had?
None
Very mild
Mild
Moderate
Severe
Very severe
41. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the
home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
42. During the past 4 weeks, how much of the time: (Select the single best answer for each question.)
None
of the
time
A little
of the
time
Some
of the
time
A good
bit of
the time
Most
of the
time
All
of the
time
a. Did you feel full of pep?
b. Have you been a very nervous person?
c. Have you felt so down in the dumps that
nothing could cheer you up?
d. Have you felt calm and peaceful?
e. Did you have a lot of energy?
f.
Have you felt downhearted and blue?
g. Did you feel worn out?
h. Have you been a happy person?
i.
Did you feel tired?
43. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with
your social activities (like visiting with friends, relatives)?
None of the time
A little of the time
Some of the time
Page 13
Most of the time
All of the time
5735525204
44. Please choose the answer that best describes how true or false each of the following statements is for you.
Definitely
true
Mostly
true
Not sure
Mostly
false
Definitely
false
a. I seem to get sick a little easier than other people
b. I am as healthy as anybody I know
c. I expect my health to get worse
d. My health is excellent
45. Compared to 3 years ago, how would you rate your physical health in general now?
Much better
Somewhat better
About the same
Somewhat worse
Much worse
46. Compared to 3 years ago, how would you rate your emotional health or well-being (such as feeling anxious,
depressed, or irritable) now?
Much better
Somewhat better
About the same
Somewhat worse
Much worse
47. Other than conventional medicine, what other health treatments have you used in the last 12 months?
a. Acupuncture
No
Yes
g. High dose/megavitamin therapy
No
Yes
b. Biofeedback
No
Yes
h. Homeopathy
No
Yes
c. Chiropractic care
No
Yes
i.
Hypnosis
No
Yes
d. Energy healing
No
Yes
j.
Massage
No
Yes
e. Folk remedies
No
Yes
k. Relaxation
No
Yes
f.
No
Yes
l.
No
Yes
a. Body building supplements (such as amino acids, weight gain products, creatine, etc.)
No
Yes
b. Energy supplements (such as energy drinks, pills, or energy enhancing herbs)
No
Yes
c. Weight loss supplements
No
Yes
Herbal therapy
Spiritual healing
48. Have you taken any of the following supplements in the last 12 months?
49. a. Have you ever received the anthrax vaccine?
No
Yes
No
Yes
b. If YES, how many shots of the anthrax vaccine have you received?
50. Have you received the smallpox vaccine after 2001?
Page 14
8683525209
These next few questions are about drinking alcoholic beverages. Alcoholic beverages include beer, wine, and liquor
(such as whiskey, gin, etc.). For the purpose of this questionnaire:
One drink = one 12-ounce beer, one 4-ounce glass of wine, or one 1.5-ounce shot of liquor
51. In your entire life, have you had at least 12 drinks of any type of alcoholic
beverage (including beer and wine)?
No
Yes
If you marked NO, skip to question 62 on page 16
52. In the past year, how often did you typically drink any type of alcoholic beverage?
Never
Rarely
Monthly
Weekly
Daily
If you marked NEVER, skip to question 62 on page 16
53. In the past year, on those days that you drank alcoholic beverages,
on average, how many drinks did you have?
drinks
54. In a typical week, how many drinks do you have?
drinks
55. In a typical week, how many drinks of each type of
alcoholic beverage do you have?
beer(s)
wine
liquor
56. Last week, how many drinks of alcoholic beverages did you have?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
days
57. In the past year, on how many days did you have 5 or more drinks of any alcoholic beverage?
58. In the past year, how often did you typically get drunk (intoxicated)?
Never
Monthly or less
2-4 times a month
>4 times per month
59. FOR MEN ONLY:
In the past year, how often did you typically have 5 or more drinks of alcoholic beverages within a 2-hour period?
Never
Monthly or less
2-4 times a month
>4 times per month
60. FOR WOMEN ONLY:
In the past year, how often did you typically have 4 or more drinks of alcoholic beverages within a 2-hour period?
Never
Monthly or less
2-4 times a month
Page 15
>4 times per month
1622525205
61. In the last 12 months, have any of the following happened to you more than once?
a. You drank alcohol even though a doctor suggested that you stop drinking because of a
problem with your health
No
Yes
b. You drank alcohol, were high from alcohol, or hung over while you were working, going to
school, or taking care of children or other responsibilities
No
Yes
c. You missed or were late for work, school, or other activities because you were drinking or hung
over
No
Yes
d. You had a problem getting along with people while you were drinking
No
Yes
e. You drove a car after having several drinks or after drinking too much
No
Yes
a. Felt you needed to cut back on your drinking
No
Yes
b. Felt annoyed at anyone who suggested you cut back on your drinking
No
Yes
c. Felt you needed an "eye-opener" or early morning drink
No
Yes
d. Felt guilty about your drinking
No
Yes
a. Cigarettes
No
Yes
b. Cigars
No
Yes
c. Pipes
No
Yes
d. Smokeless tobacco (chew, dip, snuff)
No
Yes
No
Yes
62. Have you ever felt any of the following?
63. In the past year, have you used any of the following tobacco products?
64. In your lifetime, have you smoked at least 100 cigarettes (5 packs)?
If you marked NO, skip to question 69 on page 17
65. At what age did you start smoking?
years old
66. How many years have or did you smoke an average of at least 3 cigarettes per day
(or one pack per week)?
years
67. When smoking, how many packs per day did you or do you smoke?
68. Have you ever tried to quit smoking?
Less than half a pack per day
Yes, and succeeded
Half to 1 pack per day
Yes, but not successfully
1 to 2 packs per day
No
More than 2 packs per day
Page 16
4048525200
69. Have you ever had any of the following life events happen to you?
If YES, list
most recent year
a. You moved or changed residence more than once
No
Yes
b. You changed job, assignment, or career path involuntarily (for example,
you lost a job, or you had to take a job you did not like)
No
Yes
c. You or your partner had an unplanned pregnancy
No
Yes
d. You were divorced or separated
No
Yes
e. Suffered major financial problems (such as bankruptcy)
No
Yes
f.
No
Yes
g. Experienced sexual harassment
No
Yes
h. Suffered a violent assault
No
Yes
i.
Had a family member or loved one who became severely ill
No
Yes
j.
Had a family member or loved one who died
No
Yes
No
Yes
Suffered forced sexual relations or sexual assault
k. Suffered a disabling illness or injury
70. Have you ever been PERSONALLY exposed to any of the following?
(do not include TV, video, movies, computers, or theater)
No
a. Witnessing a person's death due to war, disaster, or tragic event
b. Witnessing instances of physical abuse (torture, beating, rape)
c. Dead and/or decomposing bodies
d. Maimed soldiers or civilians
e. Prisoners of war or refugees
f.
Chemical or biological warfare agents
g. Medical countermeasures for chemical or biological
warfare agent exposure
h. Alarms necessitating wearing of chemical or biological
warfare protective gear
Page 17
Yes,
1 time
Yes,
more than
1 time
If YES, list
most recent year
of exposure
5185525203
71. During the past 3 years, were you PERSONALLY exposed to any of the following?
No
Don't
know
Yes
If YES, list
most recent year
of exposure
a. Occupational hazards requiring protective equipment, such
as respirators or hearing protection
2
0
0
b. Routine skin contact with paint and/or solvent and/or substances
2
0
0
c. Depleted uranium (DU)
2
0
0
d. Microwaves (excluding small microwave ovens)
2
0
0
e. Pesticides, including creams, sprays, or uniform treatments
2
0
0
f.
2
0
0
2
0
0
Pesticides applied in the environment or around living facilities
g. Any exposure, physical or psychological, during a military
deployment that had a significant impact on your health?
please specify
72. Were you ever seriously injured, such that you were hospitalized and/or lost at least one day of work?
No
Yes
If you marked NO, skip to question 74 on page 19
73. If YES: please specify year(s) and circumstances, for up to 5 different events. List most recent first. Mark all that apply.
Injury included head trauma
Year of injury event
(List each event
separately)
(lost consciousness, felt dazed,
confused or "saw stars", or had
trouble remembering injury)
Injury associated
with motor vehicle
accident/crash
1st Event
2nd Event
3rd Event
4th Event
5th Event
Page 18
Injury associated
with training
or sports
Injury associated
with combat
Other
2019525206
Please answer question 74 ONLY if you are ENLISTED (Active Duty, Reserve, or National Guard)
All others please skip to question 75 on page 20
74. Review the list of military occupational categories below. Select the two categories that best match your military job
and fill in the two-digit codes for your primary job code and your secondary job code.
PRIMARY JOB CODE
SECONDARY JOB CODE
ENLISTED MILITARY OCCUPATIONAL CATEGORIES
INFANTRY, GUN CREWS & SEAMANSHIP SPECIALISTS
FUNCTIONAL SUPPORT & ADMINISTRATION
Infantry..................................................................................... 01
Armor or Amphibious............................................................... 02
Combat Engineering................................................................ 03
Artillery/Gunnery, Rockets or Missiles..................................... 04
Air Crew................................................................................... 05
Seamanship............................................................................ 06
Installation Security................................................................. 07
Personnel............................................................................ 50
Administration......................................................................51
Clerical/Personnel............................................................... 52
Data Processing.................................................................. 53
Accounting, Finance or Disbursing...................................... 54
Other Functional Support.................................................... 55
Religious, Morale or Welfare............................................... 56
Information or Education..................................................... 57
ELECTRONIC EQUIPMENT REPAIRERS
ELECTRICAL/MECHANICAL EQUIPMENT REPAIRERS
Radio/Radar.............................................................................10
Fire Control Electric Systems, Non-Missile.............................. 11
Missile Guidance, Control or Check-out.................................. 12
Sonar Equipment..................................................................... 13
Nuclear Weapons Equipment.................................................. 14
ADP Computers....................................................................... 15
Teletype or Cryptographic Equipment..................................... 16
Other Electronic Equipment..................................................... 19
Aircraft or Aircraft Related................................................... 60
Automotive.......................................................................... 61
Wire Communications......................................................... 62
Missile Mechanical or Electrical...........................................63
Armament or Munitions....................................................... 64
Shipboard Propulsion.......................................................... 65
Power Generating Equipment............................................. 66
Precision Equipment............................................................67
Other Mechanical or Electrical Equipment.......................... 69
COMMUNICATIONS & INTELLIGENCE SPECIALISTS
Radio or Radio Code............................................................... 20
Sonar....................................................................................... 21
Radar or Air Traffic Control..................................................... 22
Signal Intel/Electronic Warfare................................................ 23
Intelligence...............................................................................24
Combat Operations Control..................................................... 25
Communications Center Operations........................................ 26
CRAFTWORKERS
Metalworking....................................................................... 70
Construction........................................................................ 71
Utilities................................................................................. 72
Lithography..........................................................................74
Industrial Gas or Fuel Production........................................ 75
Fabric, Leather or Rubber................................................... 76
Other Craftworker................................................................ 79
HEALTH CARE SPECIALISTS
Medical Care............................................................................ 30
Ancillary Medical Support........................................................ 31
Biomedical Sciences or Allied Health...................................... 32
Dental Care..............................................................................33
Medical Administration or Logistics..........................................34
SERVICE & SUPPLY HANDLERS
Food Service....................................................................... 80
Motor Transport................................................................... 81
Material Receipt, Storage or Issue...................................... 82
Law Enforcement................................................................ 83
Personnel Service............................................................... 84
Auxiliary Labor..................................................................... 85
Forward Area Equipment Support....................................... 86
Other Services..................................................................... 87
OTHER TECHNICAL AND ALLIED SPECIALISTS
Photography............................................................................. 40
Mapping, Surveying, Drafting or Illustrating............................. 41
Weather................................................................................... 42
Ordnance Disposal or Diving................................................... 43
Musician................................................................................... 45
Technical Specialist................................................................. 49
OTHER
Patients or Prisoners........................................................... 90
Officer Candidate or Student............................................... 91
Undesignated Occupations................................................. 92
Not Occupationally Qualified............................................... 95
Page 19
2226525206
Please answer question 75 ONLY if you are an OFFICER or WARRANT OFFICER (Active Duty, Reserve, or National
Guard) All others please skip to question 76 on page 21
75. Review the list of military occupational categories below. Select the two categories that best match your military job
and fill in the two-digit codes for your primary job code and your secondary job code.
PRIMARY JOB CODE
SECONDARY JOB CODE
OFFICER or WARRANT OFFICER MILITARY OCCUPATIONAL CATEGORIES
TACTICAL OPERATIONS OFFICERS
GENERAL OFFICERS & EXECUTIVES
Fixed-Wing Fighter or Bomber Pilot................................... 2A
Helicopter Pilot....................................................................2C
Aircraft Crew.......................................................................2D
Ground or Naval Arms........................................................2E
Missiles.............................................................................. 2F
Operations Staff................................................................. 2G
Civilian Pilot........................................................................2H
General or Flag.........................................................................1A
Executive...................................................................................1B
INTELLIGENCE OFFICERS
Intelligence, General......................................................... 3A
Communications Intelligence............................................ 3B
Counter-intelligence........................................................... 3C
ENGINEERING & MAINTENANCE OFFICERS
Construction or Utilities...................................................... 4A
Electrical or Electronic........................................................4B
Communications or Radar................................................. 4C
Aviation Maintenance or Allied........................................... 4D
Ordnance........................................................................... 4E
Missile Maintenance...........................................................4F
Ship Construction or Maintenance..................................... 4G
Ship Machinery...................................................................4H
Safety................................................................................. 4J
Chemical............................................................................ 4K
Automotive or Allied........................................................... 4L
Surveying or Mapping....................................................... 4M
Other.................................................................................. 4N
SCIENTISTS & PROFESSIONALS
Physical Scientist............................................................... 5A
Meteorologist......................................................................5B
Biological Scientist............................................................. 5C
Social Scientist...................................................................5D
Psychologist....................................................................... 5E
Legal.................................................................................. 5F
Chaplain............................................................................. 5G
Social Worker.................................................................... 5H
Mathematician or Statistician............................................. 5J
Educator or Instructor.........................................................5K
Research & Development Coordinator...............................5L
Community Activities Officer.............................................. 5M
Scientist or Professional.....................................................5N
HEALTH CARE OFFICERS
Physician..................................................................................6A
Dentist.......................................................................................6C
Nurse....................................................................................... 6E
Veterinarian...............................................................................6G
Biomedical Sciences or Allied Health........................................6H
Health Service Administration..................................................6I
ADMINISTRATORS
Administrator, General............................................................. 7A
Training Administrator..............................................................7B
Manpower or Personnel............................................................7C
Comptroller or Fiscal................................................................7D
Data Processing.......................................................................7E
Pictorial.................................................................................... 7F
Information............................................................................... 7G
Police....................................................................................... 7H
Inspection.................................................................................7L
Morale & Welfare..................................................................... 7N
SUPPLY, PROCUREMENT & ALLIED OFFICERS
Logistics, General.................................................................... 8A
Supply...................................................................................... 8B
Transportation..........................................................................8C
Procurement or Production...................................................... 8D
Food Service............................................................................8E
Exchange or Commissary........................................................8F
Other........................................................................................ 8G
OTHER
Patient......................................................................................9A
Student.....................................................................................9B
Other........................................................................................ 9E
Page 20
9843525208
76. Do you have a civilian job at this time?
YES
Go to question 77
NO civilian employment at this time
Go to question 78
Homemaker
Go to question 78
Please answer question 77 ONLY if you answered YES to question 76
All others please skip to question 78 on page 22
77. Review the list of civilian occupational categories on this page and the next page. Select the two categories that best
match your civilian job and fill in the three-digit codes for your primary and your secondary job codes.
PRIMARY JOB CODE
SECONDARY JOB CODE
CIVILIAN OCCUPATIONAL CATEGORIES
More categories listed on page 22
ARCHITECTURE & ENGINEERING
EDUCATION, TRAINING & LIBRARY
Architect, Surveyor or Cartographer ...............................171
Engineer.......................................................................... 172
Drafter, Engineering or Mapping Technician................... 173
Postsecondary Teacher................................................. 251
Primary, Secondary or Special Education
School Teacher............................................................. 252
Other Teacher or Instructor............................................253
Librarian, Curator or Archivist........................................ 254
Other Education, Training or Library Occupation...........259
ARTS, DESIGN, MEDIA, ENTERTAINMENT & SPORTS
Art or Design................................................................... 271
Entertainer, Performer, Sports or Related Worker.......... 272
Media Communication Worker........................................273
Media Communication Equipment Worker......................274
FARMING, FISHING & FORESTRY WORKERS
Supervisor, Farming, Fishing or Forestry Worker..........451
Agricultural Worker........................................................ 452
Fishing or Hunting Worker............................................. 453
Forest, Conservation or Logging Worker.......................454
Other Farming, Fishing or Forestry................................459
BUILDING & GROUNDS CLEANING & MAINTENANCE
Supervisor, Building & Grounds, Cleaning &
Maintenance Worker....................................................... 371
Building Cleaning or Pest Control................................... 372
Ground Maintenance.......................................................373
FOOD PREPARATION & SERVING RELATED
Supervisor, Food Preparation or Serving.......................3511
Cook or Food Preparation Worker.................................352
Food and Beverage Worker...........................................353
Other Food Preparation or Serving Related Worker......359
BUSINESS & FINANCIAL OPERATIONS
Business Operations Specialist.......................................131
Financial Specialist..........................................................132
HEALTH CARE
COMMUNITY & SOCIAL SERVICES
Counselor, Social Worker or Other Community
or Social Service Specialist............................................. 211
Religious Worker.............................................................212
Physician........................................................................295
Nursing, Psychiatric or Home Health Aid....................... 311
Occupational or Physical Therapist Assistant or Aid......312
Other Health Care Occupation.......................................319
COMPUTER & MATHEMATICAL
INSTALLATION, REPAIR & MAINTENANCE
Computer Specialist ........................................................151
Mathematical Specialist...................................................152
Mathematical Technician.................................................153
Supervisor of Installation, Maintenance
or Repair Worker........................................................... 491
Electrical or Electric Equipment Mechanic,
Installer or Repairer....................................................... 492
Vehicle or Mobile Equipment Mechanic,
Installer or Repairer....................................................... 493
Other Installation, Maintenance or Repair......................499
CONSTRUCTION & EXTRACTION
Supervisor, Construction or Extraction Worker............... 471
Construction Trades Worker........................................... 472
Helper, Construction Trades........................................... 473
Other Construction or Related Worker............................474
Extraction Worker............................................................475
Page 21
More categories listed on page 22...
3091525207
Question 77 continued, Civilian occupational categories...
CIVILIAN OCCUPATIONAL CATEGORIES
LEGAL
PRODUCTION
Lawyer, Judge or Related Worker................................. 231
Legal Support Worker....................................................232
Life Scientist...................................................................191
Physical Scientist........................................................... 192
Social Scientist or Related Worker................................ 193
Life, Physical or Social Sciences Technician................. 194
Supervisor, Production Worker.....................................511
Assembler, Fabricator...................................................512
Food Processing Worker..............................................513
Metal or Plastic Worker.................................................514
Printing Worker.............................................................515
Textile, Apparel or Furnishing Worker..........................516
Woodworker..................................................................517
Plant or Systems Operator............................................518
Other Production Occupation....................................... 519
MANAGEMENT
PROTECTIVE SERVICES
Top Executive................................................................ 111
Advertising, Marketing, Promotions, PR or
Sales Manager...............................................................112
Operations Specialties Manager....................................113
Other Management Occupation.....................................119
First Line Supervisor/Manager, Protective Services.....331
Firefighting or Prevention Worker.................................332
Law Enforcement Worker.............................................333
Other Protective Service Worker..................................339
LIFE, PHYSICAL & SOCIAL SCIENCES
SALES-RELATED
OFFICE & ADMINISTRATIVE SUPPORT
Supervisor, Sales..........................................................411
Retail Sales Worker......................................................412
Sales Representative, Services....................................413
Sales Representative, Wholesale or Manufacturing.....414
Counter or Rental Clerk or Parts Salesperson..............415
Other Sales or Related Worker.....................................419
Supervisor, Office or Administrative Support................. 431
Communications Equipment Operator...........................432
Financial Clerk............................................................... 433
Information or Record Clerk...........................................434
Material Recording, Scheduling, Dispatching
or Distributing Worker.................................................... 435
Secretary or Administrative Assistant............................ 436
Other Office or Administrative Support.......................... 439
TRANSPORTATION & MATERIAL MOVING
Supervisor, Transportation or Material Moving.............531
Motor Vehicle Operator.................................................533
Rail Transportation Worker...........................................534
Water Transportation....................................................535
Other Transportation.....................................................536
Material Moving Worker................................................537
PERSONAL CARE SERVICE
Supervisor, Personal Care or Service............................391
Animal Care or Service.................................................. 392
Entertainment Attendant or Related Worker..................393
Funeral Worker.............................................................. 3941
Personal Appearance.................................................... 395
Transportation, Tourism or Lodging Attendant.............. 396
Other Personal Care or Service Worker........................ 399
Negative
Neither
Somewhat Negative nor Somewhat
Negative
Positive
Positive
Positive
78. What is your overall feeling about your military service?
79. Are you currently serving in the military (Active Duty, Reserve, or National Guard)?
Page 22
No
Yes
9160525200
80. Since 2001, have you received imminent danger pay, hardship duty pay, or combat zone
tax exclusion benefits for deployment to any of the regions listed below?
No
Yes
If you marked NO, skip to question 84 on page 24
Country Codes
01 Afghanistan
02 Bahrain
03 Bosnia or Herzegovina
04 Croatia
05 Iraq
06 Kuwait
07 Kyrgyzstan
08 Macedonia
09 Montenegro
10 Oman
11
Pakistan
Sea Codes
12
Philippines
21 Adriatic Sea
13
Qatar
22 Arabian Sea
14
Saudi Arabia
23 Gulf of Aden
15
Serbia (includes Kosovo)
24 Gulf of Oman
16
Tajikistan
25 Persian Gulf
17
Turkey
26 Red Sea
18
United Arab Emirates
27 Other sea area
19
Uzbekistan
20
Other country
please specify
please specify
81. If YES: use the country and sea codes (01-27) assigned to the locations above to indicate the region(s) where you
received imminent danger pay, hardship duty pay, or combat zone tax exclusion benefits. Please list most recent first.
Location
Date Arrived
Month
/
Date Departed
Year
Month
/
Year
a.
/
2
0
0
TO
/
2
0
0
b.
/
2
0
0
TO
/
2
0
0
c.
/
2
0
0
TO
/
2
0
0
d.
/
2
0
0
TO
/
2
0
0
e.
/
2
0
0
TO
/
2
0
0
82. Since 2001, have you been to more regions where you received imminent danger pay, hardship
duty pay, or combat zone tax exclusion benefits than fit into the space allowed above?
No
Yes
83. Since 2001, how often have you experienced the following during deployment?
Never
1 time
More than
1 time
List most
recent year
of exposure
a. Feeling that you were in great danger of being killed
2
0
0
b. Being attacked or ambushed
2
0
0
c. Receiving small arms fire
2
0
0
d. Clearing / searching homes or buildings
2
0
0
Question 83 continued on page 24...
Page 23
2649525205
Question 83 continued...
Since 2001, how often have you experienced the following during deployment?
Never
1 time
More than
1 time
List most
recent year
of exposure
e. Having an improvised explosive device (IED)
or booby trap explode near you
2
0
0
f.
2
0
0
g. Seeing dead bodies or human remains
2
0
0
h. Handling or uncovering human remains
2
0
0
i.
Knowing someone seriously injured or killed
2
0
0
j.
Seeing Americans who were seriously injured
or killed
2
0
0
2
0
0
2
0
0
2
0
0
Being wounded or injured
k. Having a member of your unit be seriously
injured or killed
l.
Being directly responsible for the death of
enemy combatant
m. Being directly responsible for the death of a
non-combatant
84. Do you have any concerns about your health that are not covered in this questionnaire that you would like to share?
(Continue on a separate sheet if necessary.)
Thank you for completing this important questionnaire!
PRIVACY ACT STATEMENT: You have rights under the Privacy Act. The following statement describes how that Act applies to this study:
Authority: Authority to request this information is granted under Title 5, U.S. Code 136, Department of Defense Regulations, Executive Order 9396, DoD RCS#DD-HA(AR)2106,
and OMB #0720-0029. Personal identifiers will be used to link survey data with medical and other military records.
Purpose: Medical research information will be collected in a research project titled "Prospective Studies of U.S. Military Forces: The Millennium Cohort Study." The project
objective is to enhance basic medical knowledge and to improve the treatment and prevention of illnesses that may be related to military service.
Routine Uses: The information provided in this questionnaire will be maintained in data files at the DoD Center for Deployment Health Research at the Naval Health Research
Center and used only for medical research purposes. Use of these data may be granted to other federal and non-federal medical research agencies as approved by the Naval
Health Research Center's Institutional Review Board. However, your personal identifiers will be protected. By signing the enclosed consent form, you are volunteering to disclose
your information as identified above. If you do not agree to this disclosure, your failure will make the research less useful. The "Blanket Routine Uses" that appears at the
beginning of the Department of Defense's compilation of medical databases also applies to this system.
Anonymity: All responses will be held in confidence by the DoD Center for Deployment Health Research. Information you provide will be considered only when statistically
summarized with the responses of others. Your personal identifiers (name, etc) will only be used to link data sets and then the identifiers will be stripped from study data such that
medical researchers cannot identify you individually.
Voluntary Disclosure: Completion of the questionnaire is voluntary. Failure to respond to any of the questions will NOT result in any disadvantages or penalties except possible
lack of representation of your views in the final results and outcomes.
Page 24
| File Type | application/pdf |
| File Title | MilCo 2007 New Enrollee (52520 |
| Author | welch |
| File Modified | 2009-03-06 |
| File Created | 2006-11-27 |