Form VA Form 10-21087 VA Form 10-21087 Deployment Experiences Survey Follow Up Study

VA Form 10-21087

OMB Number 2900-0730

Estimated Burden: 45 MIN.

DEPLOYMENT EXPERIENCES SURVEY FOLLOW-UP STUDY

This booklet contains a range of questions about your experiences after deployment. The purpose of this follow-up study is to better understand Veterans’ workplace and family experiences, as well as to understand Veterans’ use of VA services. We hope that the information we obtain from this study can be used to further prepare future military personnel for the challenges of being deployed overseas, and help us better understand how to assist Veterans after their deployment.

Questionnaire Instructions

We would like you to answer all the questions on the following pages as completely as possible. We are interested in your opinions. Please remember that you are free to decide not to answer any question that makes you feel uncomfortable. You are free to skip questions without any penalty or prejudice.

Information obtained about you from this questionnaire will be considered privileged and held in

confidence; you will not be identified in any presentation of the results. Only your unique study

identification number will appear on these questionnaire pages.

• Please fill in the circle completely as shown here: ●

• It is best to use a soft lead pencil in case you want to change an answer.

• If you are unsure about how to answer a question, please give the best answer you can.

• Answer each question unless you are asked to skip to another question.

• Fill in only one answer circle for each question unless it tells you to "Mark all that apply".

• When you are finished, please place the questionnaire in the enclosed postage-paid envelope and put it in the mail.

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.

BAR CODE

SECTION A: EMPLOYMENT

1. What is your current employment situation as of today?

____Employed

____Self-employed

____Looking for work; unemployed

____Temporarily laid off

____Retired

____Homemaker

____Student

____Maternity leave

____Illness/Sick leave

____Disabled

____Other___________________________

2. Have you experienced periods of involuntary unemployment during the past year? ___Yes ___ No

If yes, approximately how much time over the past year were you unemployed in total?

____Less than 1 month

____1-3 months

____4-6 months

____7-9 months

____10 months or longer

3. What is your (spouse/partner)’s current employment status?

____Employed

____Self-employed

____Looking for work; unemployed

____Temporarily laid off

____Retired

____Homemaker

____Student

____Maternity leave

____Illness/Sick leave

____Disabled

____Other___________________________

4. Which of the following categories best describes your 2012 household income before taxes?

____$15,000 or less

____$15,001 - $25,000

____$25,001 - $35,000

____$35,001 - $50,000

____$50,001 - $75,000

____$75,001 - $100,000

____Over $100,000

SECTION B: EMPLOYMENT HOURS AND PERFORMANCE

If you have not been working for pay during the past 30 days, skip this section and continue with the next section, SECTION C. Otherwise, please answer the following questions:

1. How many hours does your employer expect you to work in a typical 7-day week? _______

2. How many days of work have you missed in the last four weeks? _______

3. How many total hours have you worked in the last four weeks? _______

4. On a scale from 0 to 10 where 0 is the worst job performance anyone could have at your job and 10 is the performance of a top worker, how would you rate the usual performance of most workers in a job similar to yours? ______

5. Using the same 0 – 10 scale, how would you rate your overall job performance on the days you worked during the past 4 weeks (28 days)? ______

SECTION C: WORK SATISFACTION (INCLUDING HOME-BASED WORK AND WORK AS A HOMEMAKER):

If you have not worked in the past 30 days for pay, as a volunteer, or as a homemaker, skip this section and continue with the next section (SECTION D). Otherwise, please answer the following questions regarding your current work.

Do the following adjectives describe your work overall?	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
Good	1	2	3	4	5
Undesirable	1	2	3	4	5
Better than most	1	2	3	4	5
Disagreeable	1	2	3	4	5
Makes me content	1	2	3	4	5
Excellent	1	2	3	4	5
Enjoyable	1	2	3	4	5
Poor	1	2	3	4	5

SECTION D: WORK (INCLUDING HOME-BASED WORK)

Have you worked (either for pay or as a volunteer) in the past 30 days? ____Yes ____No

If you have not worked either for pay or as a volunteer during the past 30 days skip this section and continue with the

next section (SECTION E). Otherwise, please answer the following questions:

Over the past 30 days…	Never			Sometimes			Always
I had trouble showing up on time for work.	1	2	3	4	5	6	7
I reported for work when I was supposed to.	1	2	3	4	5	6	7
I got along well with others at work.	1	2	3	4	5	6	7
I stayed interested in my work.	1	2	3	4	5	6	7
I had trouble being patient with others at work.	1	2	3	4	5	6	7
I performed my job to the best of my ability.	1	2	3	4	5	6	7
I completed my work on time.	1	2	3	4	5	6	7
I had trouble settling arguments or disagreements with others at work.	1	2	3	4	5	6	7
I solved problems or challenges at work without much difficulty.	1	2	3	4	5	6	7
I maintained a reasonable balance between work and home.	1	2	3	4	5	6	7
I was able to perform my work duties without needing any extra help.	1	2	3	4	5	6	7
When necessary, I cooperated on work-related tasks with others.	1	2	3	4	5	6	7
I showed my skills and knowledge of the job.	1	2	3	4	5	6	7
I showed others at work that they could depend on me.	1	2	3	4	5	6	7
I came up with ideas and put them into action at work.	1	2	3	4	5	6	7
I took responsibility for my work.	1	2	3	4	5	6	7
I prioritized work-related tasks appropriately.	1	2	3	4	5	6	7
I worked hard every day.	1	2	3	4	5	6	7
I made sure that the work environment was pleasant for others.	1	2	3	4	5	6	7
I had trouble expressing my ideas, thoughts or feelings to others at work.	1	2	3	4	5	6	7
I had trouble being supportive of others at work.	1	2	3	4	5	6	7

	Not at all			Somewhat			Very much
22a. Overall, over the past 30 days, I had trouble at work.	1	2	3	4	5	6	7
22b. Overall, in the past 30 days, I was distressed or emotionally upset because of my difficulties at work.	1	2	3	4	5	6	7

SECTION E: EDUCATION (INCLUDING DISTANCE LEARNING)

If you have not been involved in an educational experience during the past 30 days, skip this section and continue with the next section, SECTION F. Otherwise, please answer the following questions:

Over the past 30 days…	Never			Sometimes			Always
I attended class regularly.	1	2	3	4	5	6	7
I stayed interested in my classes and schoolwork.	1	2	3	4	5	6	7
I arrived on time for my classes.	1	2	3	4	5	6	7
I had trouble being supportive of my classmates’ achievements.	1	2	3	4	5	6	7
I turned in assignments late.	1	2	3	4	5	6	7
I solved problems and challenges in class without much difficulty.	1	2	3	4	5	6	7
I took responsibility for my schoolwork.	1	2	3	4	5	6	7
I was patient with my classmates and/or instructors.	1	2	3	4	5	6	7
I had trouble settling disagreements or arguments with instructors and/or classmates.	1	2	3	4	5	6	7
I had trouble remembering what the instructor said.	1	2	3	4	5	6	7
I could easily remember what I read.	1	2	3	4	5	6	7
I understood course material.	1	2	3	4	5	6	7
When necessary, I cooperated with classmates.	1	2	3	4	5	6	7
I got along with classmates and/or instructors.	1	2	3	4	5	6	7
I completed my schoolwork to the best of my ability.	1	2	3	4	5	6	7

	Not at all			Somewhat			Very much
16a. Overall, over the past 30 days, I had trouble at school.	1	2	3	4	5	6	7
16b. Overall, in the past 30 days, I was distressed or emotionally upset because of my difficulties at school.	1	2	3	4	5	6	7

SECTION F: PERCEIVED UNDEREMPLOYMENT

If you have not worked either for pay or as a volunteer during the past 30 days skip this section and continue with the

next section (SECTION G). Otherwise, please answer the following questions:

	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
My job requires less education than I have.	1	2	3	4	5
The work experience that I have is not necessary to be successful on this job.	1	2	3	4	5
I have job skills that are not required for this job.	1	2	3	4	5
Someone with less education than myself could perform well on my job.	1	2	3	4	5
My previous training is not being fully utilized on this job.	1	2	3	4	5
I have a lot of knowledge that I do not need in order to do my job.	1	2	3	4	5
My education level is above the education level required by my job.	1	2	3	4	5
Someone with less work experience than myself could do my job just as well.	1	2	3	4	5
I have more abilities than I need in order to do my job.	1	2	3	4	5

SECTION G: WORK-FAMILY CONFLICT

If you have not worked either for pay or as a volunteer during the past 30 days skip this section and continue with the

next section (SECTION H). Otherwise, please answer the following questions:

	None of the time	A little of the time	Some of the time	Most of the time	All of the time
How often does your job or career interfere with your responsibilities at home, such as yard work, cooking, cleaning, repairs, shopping, paying the bills, or child care?	1	2	3	4	5
How often does your job or career keep you from spending the amount of time you would like to spend with your family?	1	2	3	4	5
How often does your home life interfere with your responsibilities at work, such as getting to work on time, accomplishing daily tasks, or working overtime?	1	2	3	4	5
How often does your home life keep you from spending the amount of time you would like to spend on job- or career-related activities?	1	2	3	4	5

SECTION H: RELATIONSHIP STATUS

1. What is your current marital status?

____Married

____Divorced

____Living as a couple

____Widowed

____Separated

____Single/Never married

2. How long have you been in your current relationship status?

____< 6 months

____7 months – 3 years

____3 years – 5 years

____5 years – 10 years

____10 years – 20 years

____ > 20 years

SECTION I: ROMANTIC RELATIONSHIP EXPERIENCES

If you have not been in a romantic relationship with a spouse or partner during the past 30 days, skip this section and continue with the next section, SECTION J. Otherwise, please answer the following questions:

Over the past 30 days…	Never			Sometimes			Always
When necessary, I cooperated on tasks with my spouse or partner.	1	2	3	4	5	6	7
I shared household chores or duties with my spouse or partner.	1	2	3	4	5	6	7
I had trouble sharing thoughts or feelings with my spouse or partner.	1	2	3	4	5	6	7
I showed interest in my spouse or partner’s activities.	1	2	3	4	5	6	7
I had trouble settling arguments or disagreements with my spouse or partner.	1	2	3	4	5	6	7
I was patient with my spouse or partner.	1	2	3	4	5	6	7
I had trouble giving emotional support to my spouse or partner.	1	2	3	4	5	6	7
I was affectionate with my spouse or partner.	1	2	3	4	5	6	7
My partner or spouse and I did activities that brought us closer together.	1	2	3	4	5	6	7
I was interested in sexual activity with my spouse or partner.	1	2	3	4	5	6	7
I had trouble becoming sexually aroused with my spouse or partner.	1	2	3	4	5	6	7

Overall, over the past 30 days…	Not at all			Somewhat			Very much
12a. I had trouble in my romantic relationship with my spouse or partner.	1	2	3	4	5	6	7

Overall, over the past 30 days…	Not at all			Somewhat			Very much
12b. I was distressed or emotionally upset because of the difficulties I had in my romantic relationship.	1	2	3	4	5	6	7

SECTION J: ROMANTIC RELATIONSHIP CONFLICTS

If you have not been in a romantic relationship with a spouse or partner during the past year, please skip this section and continue on with the next section, SECTION K. If you have been in a romantic relationship, even if you’re not in the relationship currently, please answer the following questions by indicating how many times you did each of these things in the past year, and how many times your partner did them in the past year. If you or your partner did not do one of these things in the past year, but it happened before that, mark a “7” on your answer sheet for that question. If it never happened, mark an “8” on your answer sheet.

How often did this happen in the past year?	Once	Twice	3 -5 times	6 – 10 times	11 – 20 times	More than 20 times	Not in the past year, but it did happen before	This has never happened
I insulted, swore, shorted or yelled at my partner.	1	2	3	4	5	6	7	8
My partner insulted, swore, shouted or yelled at me.	1	2	3	4	5	6	7	8
I pushed, shoved, or slapped my partner.	1	2	3	4	5	6	7	8
My partner pushed, shoved, or slapped me.	1	2	3	4	5	6	7	8
I punched, kicked or beat-up my partner.	1	2	3	4	5	6	7	8
My partner punched, kicked or beat-me-up.	1	2	3	4	5	6	7	8
I destroyed something belonging to my partner or threatened to hit my partner.	1	2	3	4	5	6	7	8
My partner destroyed something belonging to me or threatened to hit me.	1	2	3	4	5	6	7	8
I used force (like hitting, holding down, or using a weapon) to make my partner have sex.	1	2	3	4	5	6	7	8
My partner used force (like hitting, holding down, or using a weapon) to make me have sex.	1	2	3	4	5	6	7	8
I insisted on sex when my partner did not want to or insisted on sex without a condom (but did not use physical force.)	1	2	3	4	5	6	7	8
My partner insisted on sex when I did not want to or insisted on sex without a condom (but did not use physical force.)	1	2	3	4	5	6	7	8

SECTION K: RELATIONSHIP SATISFACTION

If you have not been in a romantic relationship with a spouse or partner during the past 30 days, skip this section and continue with the next section, SECTION L. Otherwise, please answer the following questions:

	Low satisfaction				High satisfaction
How well does your partner meet your needs?	1	2	3	4	5
In general, how satisfied are you with your relationship?	1	2	3	4	5
How good is your relationship compared to most?	1	2	3	4	5
How often do you wish you hadn’t gotten into this relationship?	1	2	3	4	5
To what extent has your relationship met your original expectations?	1	2	3	4	5
How much do you love your partner?	1	2	3	4	5
How many problems are there in your relationship?	1	2	3	4	5

SECTION L: FAMILY EXPERIENCES

Please mark how much you agree or disagree with each statement. If you spend time in more than one family, please answer these questions about the family in which you spend the greatest amount of time.

	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
My input is sought on important family decisions.	1	2	3	4	5
I feel like I fit in with my family.	1	2	3	4	5
Family members know what I think and how I feel about things.	1	2	3	4	5
I feel like my contributions to my family are appreciated.	1	2	3	4	5
I share many common interests and activities with family members.	1	2	3	4	5
When I have problems, I tell family members about them.	1	2	3	4	5
My opinions are valued by other family members.	1	2	3	4	5
I am affectionate with family members.	1	2	3	4	5
When I get into arguments with family members, we are able to settle our differences peacefully.	1	2	3	4	5
I play an important role in my family.	1	2	3	4	5
I spend as much of my free time with family members as possible.	1	2	3	4	5
Family members tell me when they are having a problem.	1	2	3	4	5
Family members miss me when I am away from them.	1	2	3	4	5
I can be myself around family members.	1	2	3	4	5
Family members tell me how they really feel and think about things.	1	2	3	4	5
I matter to other family members.	1	2	3	4	5
I feel very close to other family members.	1	2	3	4	5
I get along well with my family members.	1	2	3	4	5

SECTION M: PARENTING

In this section, “children” refers to anyone for whom you had parenting responsibilities.

Do you have children with whom you lived or had regular contact during the past 30 days? ___Yes ___ No

If you do not have children with whom you lived or had regular contact during the past 30 days, skip this section and continue on to Section N. Otherwise, please answer the following questions.

Over the past 30 days…	Never			Sometimes			Always
My children were able to depend on me for whatever they needed.	1	2	3	4	5	6	7
I was interested in my children’s activities.	1	2	3	4	5	6	7
I had trouble communicating with my children.	1	2	3	4	5	6	7
I was affectionate with my children.	1	2	3	4	5	6	7
I appropriately shared thoughts or feelings with my children.	1	2	3	4	5	6	7
My children and I did activities that brought us closer together.	1	2	3	4	5	6	7
I talked with, or taught, my children about important life issues.	1	2	3	4	5	6	7
I was a good role model for my children.	1	2	3	4	5	6	7
I had trouble giving emotional support to my children.	1	2	3	4	5	6	7
I had trouble settling conflict or disagreements with my children.	1	2	3	4	5	6	7

	Not at all			Somewhat			Very much
11a. Overall, over the past 30 days, I had trouble in my relationship with my children.	1	2	3	4	5	6	7
11b. Overall, in the past 30 days, I was distressed or emotionally upset because of the difficulties I had in my relationship with my children.

SECTION N: PARENTAL SATISFACTION

In this section, “children” refers to anyone for whom you had parenting responsibilities.

Do you have children with whom you lived or had regular contact during the past 12 months? ___Yes ___ No

If you do not have children with whom you lived or had regular contact during the past 12 months, skip this section and continue on to Section O. Otherwise, please answer the following questions.

During the past 12 months…	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
Being a parent to my children has been an enjoyable experience.	1	2	3	4	5
I have been satisfied with the relationship with my children.	1	2	3	4	5
I have been happy with the way things have been between me and my children.	1	2	3	4	5
My children have been easy to raise.	1	2	3	4	5

SECTION O: DAY-TO-DAY ACTIVITIES

Please answer the following questions in reference to day-to-day activities and responsibilities during the past 30 days:

Over the past 30 days…	Never			Sometimes			Always
I had trouble keeping up with household chores, such as cooking and cleaning.	1	2	3	4	5	6	7
I had trouble keeping up with chores and other activities outside of the home, such as errands, shopping, and appointments.	1	2	3	4	5	6	7
I had trouble keeping up with paying bills and taking care of financial matters.	1	2	3	4	5	6	7
I had trouble maintaining ties with family and friends (such as returning phone calls, and attending social events).	1	2	3	4	5	6	7

SECTION P: 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.

In the last three months I have been bothered by...	Not at all	A little bit	Moderately	Quite a bit	Extremely
repeated, disturbing memories of my military experiences.	1	2	3	4	5
repeated, disturbing dreams of my military experiences.	1	2	3	4	5
suddenly acting or feeling as if my military experiences were happening again.	1	2	3	4	5
feeling very upset when something happened that reminded me of my military experiences.	1	2	3	4	5
trouble remembering important parts of my military experiences.	1	2	3	4	5
loss of interest in activities that I used to enjoy.	1	2	3	4	5
feeling distant or cut off from other people.	1	2	3	4	5
feeling emotionally numb, or being unable to have loving feelings for those close to me.	1	2	3	4	5
feeling as if my future will somehow be cut short.	1	2	3	4	5
trouble falling or staying asleep.	1	2	3	4	5
feeling irritable or having angry outbursts.	1	2	3	4	5
having difficulty concentrating.	1	2	3	4	5
being “super alert,” or watchful or on guard.	1	2	3	4	5
feeling jumpy or easily startled.	1	2	3	4	5
having physical reactions when something reminds me of my military experiences.	1	2	3	4	5
In the past three months, I have tried to:
avoid thinking about my military experiences, or avoid having feelings about them.	1	2	3	4	5
avoid activities or situations because they reminded me of my military experiences.	1	2	3	4	5

SECTION Q: FEELING AND EMOTIONS

Next is a set of statements about feelings you may or may not have experienced in the last three months. Please mark how much you agree or disagree with each statement.

In the last three months...	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
I have felt sad.	1	2	3	4	5
I have felt discouraged about the future.	1	2	3	4	5
I have felt like a failure.	1	2	3	4	5
I haven’t gotten as much satisfaction out of things as I used to.	1	2	3	4	5
I have been disappointed in myself.	1	2	3	4	5
I have been critical of myself for my weaknesses or mistakes.	1	2	3	4	5
I have had thoughts about killing myself.	1	2	3	4	5
I have been unable to relax.	1	2	3	4	5
I have had a fear of the worst happening.	1	2	3	4	5
I have felt terrified.	1	2	3	4	5
I have felt nervous.	1	2	3	4	5
I have had a fear of losing control.	1	2	3	4	5
I have had a fear of dying.	1	2	3	4	5
I have felt scared.	1	2	3	4	5

SECTION R: ALCOHOL USE

The following questions relate to your use of alcohol. Please mark the response corresponding to the most appropriate option.

1. In the past three months, how often have you had a drink containing alcohol?

____Never

____Monthly or less

____2-4 times per month

____2-3 times per week

____4 or more times per week

2. In the past three months, how many drinks containing alcohol have you had on a typical day when you were drinking?

____Not applicable

____1 or 2

____3 or 4

____5 or 6

____7-9

____10 or more

3. How often do you have six or more drinks if you are a man, or five or more drinks if you are a woman, on one occasion?

____Never

____Less than monthly

____Monthly

____Weekly

____Daily or almost daily

SECTION S: USE OF VA HEALTH CARE BENEFITS AND SERVICES

1. What is the name of the VA Medical Center or VA Community Based Outpatient Clinic (CBOC) that is closest to you? ______________________________

How long does it take to drive to this medical center or clinic? ____________

2. In the last 12 months, did you go to an emergency room to get care of yourself? ___Yes ___ No (if No, skip to Question #6)

3. How many times did you go to the emergency room in a VA hospital [in the last 12 months]? ______

4. How many times did you go to some other hospital emergency room [in the last 12 months]? ______

5. Who paid for your emergency room care in these other, non-VA hospitals? (Check all that apply)

____the VA

____CHAMPUS, TRICARE, or the military

____Medicare

____Medigap Insurance

____Medicaid

____Some other government program

____Private insurance from an employer, union, or directly

____You or your family

____Anyone else (OTHER)_______________________

6. In the last 12 months, did you get any outpatient care for yourself? For example: doctor visits, urgent care, routine exams, medical tests, or shots. ____Yes _____No (if No, skip to Question #10)

7. How many times did you go to a VA facility for outpatient care [in the last 12 months]? ________

8. How many times did you go somewhere else to get outpatient care [in the last 12 months]? For example: a doctor’s office, clinic, HMO, or medical facility run by someone other than the VA. ________

9. Who paid for the outpatient care you received at these other, non-VA locations? (Check all that apply)

____the VA

____CHAMPUS, TRICARE, or the military

____Medicare

____Medigap Insurance

____Medicaid

____Some other government program

____Private insurance from an employer, union, or directly

____You or your family

____Anyone else (OTHER)_______________________

10. In the last 12 months, were you hospitalized overnight in a VA hospital? ____Yes _____No (if No, skip to Question # 12)

11. How many nights did you spend in a VA hospital [in the last 12 months]? ______

12. In the last 12 months, were you hospitalized somewhere else overnight? ____Yes ____No (if No, skip to Question #15)

13. How many nights did you spend in other, non-VA hospitals? ______

14. Who paid for your night(s) in these other, non-VA hospitals? (Check all that apply)

____the VA

____CHAMPUS, TRICARE, or the military

____Medicare

____Medigap Insurance

____Medicaid

____Some other government program

____Private insurance from an employer, union, or directly

____You or your family

____Anyone else (OTHER)_______________________

15. In the last 12 months, did you get prescription medications from the VA or paid for by the VA? ____Yes ____No

16. Did you get any other prescription medications from any other source [in the last 12 months]? ____ Yes ____No (if No, skip to Question #17)

    1. Altogether, how many prescription medications, not counting refills, did you get from these other sources [in the last 12 months]? _____

17. In the last 12 months, did you get medical care from the VA or paid for by the VA because you were exposed to environmental hazards while you were in the military? ____Yes ____No

18. In the last 12 months, did you receive any other medical care for exposure to environmental hazards while you were in the military? ____Yes ____No

19. In the last 12 months, did you receive psychological counseling, therapy, alcohol or drug treatment for yourself from the VA or paid for by the VA? ____Yes ____No

20. Did you receive any other psychological counseling, therapy, alcohol or drug treatment [in the last 12 months]? ____Yes ____No

21. In the last 12 months, did you receive in-home health care for yourself form the VA or paid by the VA? ____Yes ____No

22. Did you receive in-home health care from any other sources [in the last 12 months]? ____Yes ____No

23. In the last 12 months, did you receive care for any prosthetics, including hearing aids, eye glasses or home oxygen, from the VA or paid for by the VA? ____Yes ____No

24. Did you receive any other care for prosthetics [in the last 12 months]? ____Yes ____No

SECTION T: USE OF FAMILY SERVICES

These questions ask about your use of VA family Mental Health services.

The following two questions are in reference to family education services, which are services that provide families with information on mental illness and treatment options.

1. Have you and your family used family education services led by family volunteers, such as the Family-to-Family Education Program?

____Yes ____No ____Don’t know

2. Have you and your family used family education services led by mental health professionals, such as SAFE (Support and Family Education)?

____Yes ____No ____Don’t know

The following two questions are in reference to family therapy services, which often focus on skills involving communication, listening, and problem solving.

3. Have you and your family used family therapy services in the form of individual couples therapy?

____Yes ____No ____Don’t know

4. Have you and your family used family therapy services in the form of couples therapy in groups (that is, with other couples)?

____Yes ____No ____Don’t know

SECTION U: VOCATIONAL REHABILITATION

1. Have you ever used vocational rehabilitation services from the VA, such as the Vocational Rehabilitation and Employment VetSuccess program? ____Yes ____No (If No, skip to Question #4)

2. If Yes, what kind of vocational rehabilitation services have you received? [Check all that apply]

   1. ____Comprehensive rehabilitation evaluation to determine abilities, skills, and interests for employment

   2. ____Vocational counseling and rehabilitation planning for employment services

   3. ____Employment services such as job-training, job-seeking skills, resume development, and other work

readiness assistance

4. ____Assistance finding and keeping a job, including the use of special employer incentives and job

accommodations

5. ____On the Job Training (OJT), apprenticeships, and non-paid work experiences

6. ____Post-secondary training at a college, vocational, technical or business school

7. ____Supportive rehabilitation services including case management, counseling, and medical referrals

8. ____Independent living services

3. How important were these services in helping you meet your educational goals or in helping you get a job?

____Extremely important

____Very important

____Moderately important

____Slightly important

____Not at all important

4. In the past 5 years, have you received vocational rehabilitation from any other source due to your disability?

____Yes ____No (If No, skip to Question #6)

5. Who provided the vocational rehabilitation you received during the past 5 years? (Check all that apply)

____State employment office

____State rehabilitation

____Disabled Veterans Outreach Program (DVOP)

____Private organizations [e.g. Easter Seals, Goodwill]

____VHA of Veterans Hospital

____DoD, military, or TRICARE

____Other state or federal agency

____Other private insurance company

6. Have you used any other employment assistance programs since returning from deployment, such as Hero 2 Hired or “My Next Move”? ____Yes ____No

SECTION V: EDUCATION AND TRAINING

These next few questions ask about your experience with education and training benefits provided by the Department of Veterans Affairs.

1. Excluding vocational rehabilitation, have you received any education or training benefits from the VA since you left the military? ____Yes _____No (If No, skip to SECTION W)

2. How did you use the VA educational benefit? Did you… (Check all that apply)

   1. ____Take college or university coursework leading to a bachelor or graduate degree

   2. ____Attend business, technical or vocational school training, leading to a certificate or diploma

   3. ____Participate in an apprenticeship or on-the-job training (OJT) program

   4. ____Take correspondence courses

   5. ____Take flight training

   6. ____Get tutorial assistance, refresher courses, or deficiency training

   7. ____Attend a teacher certification program

   8. ____Do something else (OTHER)

3. How important were your VA education benefits in helping you meet your educational goals or preparing you to get a better job?

____Extremely important

____Very important

____Moderately important

____Slightly important

____Not at all important

SECTION W: SERVICE-CONNECTED DISABILITY

1. Have you ever applied for VA disability benefits? ____Yes ____No

   1. If yes, what is the status of your most recent claim application?

____Approved

____Waiting for decision from VA regional office

____Waiting for decision about appeal

____Denied

2. If approved, what is the total percentage disability rating received?

______%

3. If approved, what disability rating did you receive for disability related to your mental health?

______%

4. If approved, what disability rating did you receive related to your physical health?

______%

2. Are you currently receiving regular disability payments from the VA? ____Yes ____No

3. Are you receiving any of the following: (Check all that apply)

   1. ____Service-connected disability compensation

   2. ____Non-service-connected disability pension

   3. ____Anything else (OTHER)_______________________________

4. Does your pension include either aid and assistance, or household-bound benefits? ____Yes ____No ____N/A

5. During the past year, how important was the disability payment benefit you received from the VA in helping you meet your financial needs?

____Extremely important

____Very important

____Moderately important

____Slightly important

____Not at all important

____N/A

6. Have you ever received regular monetary benefits from any other source due to your disability? ____Yes ____No

(if No, skip to SECTION X)

7. From whom have you received these benefits? (Check all that apply)

____Military disability

____Military retirement

____Social Security

____State, Medicaid, SSI

____Workers Compensation

____Long-term disability insurance [from employer or self-purchased]

____Other:_________________________________

SECTION X: CURRENT HEALTH

1. In general, would you say your health is:

____Excellent

____Very good

____Good

____Fair

____Poor

2. Does your health now limit you in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

____No, not limited at all

____Yes, limited a little

____Yes, limited a lot

3. Does your health now limit you in climbing several flights of stairs?

____No, not limited at all

____Yes, limited a little

____Yes, limited a lot

In the past four weeks…	Not at all	A little bit	Moderately	Quite a bit	Extremely
4. have you accomplished less than you would like as a result of your physical health?	1	2	3	4	5
5. have you been limited in your work or other activities as a result of your physical health?	1	2	3	4	5
6. have you accomplished less than you would like as a result of any emotional problems (such as feeling depressed or anxious)?	1	2	3	4	5
7. have you not done work or other activities as carefully as usual as a result of any emotional problems?	1	2	3	4	5
8. how much did pain interfere with your normal work (including both work outside the home and housework)?	1	2	3	4	5

How much of the time during the past four weeks…	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
9. have you felt calm and peaceful?	1	2	3	4	5	6
10. did you have a lot of energy?	1	2	3	4	5	6
11. have you felt downhearted and blue?	1	2	3	4	5	6

How much of the time during the past four weeks…	None of the time	A little of the time	Some of the time	Most of the time	All of the time
12. has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?	1	2	3	4	5

SECTION Y: SATISFACTION WITH LIFE

Below are five statements that you may agree or disagree with. Using the 1 - 7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding that item. Please be open and honest in your responding.

	Strongly disagree	Disagree	Slightly disagree	Neither agree nor disagree	Slightly agree	Agree	Strongly agree
In most ways my life is close to my ideal	1	2	3	4	5	6	7
The conditions of my life are excellent.	1	2	3	4	5	6	7
I am satisfied with my life.	1	2	3	4	5	6	7
So far I have gotten the important things I want in my life.	1	2	3	4	5	6	7
If I could live my life over, I would change almost nothing.	1	2	3	4	5	6	7

SECTION Z: ADDITIONAL SURVEY INFORMATION

1. What is the highest grade or level of education you have completed? [PLEASE CHECK ONE]

____8^th 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

2. What is the highest grade or level of education you have completed? [PLEASE CHECK ONE]

____8^th 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

3. Do you have any children? ____Yes ____No

If Yes, how many children do you have? ________

What are their ages in years?

Child 1: _____ Child 2: ______ Child 3:_____ Child 4:_____ Child 5: _____

4. Who do you live with? [PLEASE CHECK ALL THAT APPLY]

____My husband, wife or partner

____My children

____My parents or in-laws

____Other relatives

____Other people who are not related to me

____No one else; I live alone

____Other temporary housing

5. How many adults currently live in your household? ________

6. How many children currently live in your household? _______

Please take a moment to go back through the survey and make sure you haven’t skipped any pages.

Thank you for your service and for your participation!

Please return questionnaire using the envelope provided to:

Dr. Dawne Vogt

VA Boston Healthcare System

150 South Huntington Avenue (116B3)

Boston, MA 02130