Form 10-21087 Reformatted WFF Survey

VA Form 10-21087

OMB Number 2900-0730

Estimated Burden: 45 min.

Exp. Date: XX/XX/XXXX

DEPLOYMENT EXPERIENCES

FOLLOW-UP STUDY

This booklet contains questions about your experiences after deployment. The purpose of this follow-up study is to better understand Veterans’ workplace and family experiences after deployment. With the information we obtain from this study, we can better understand how to assist Veterans after they return from deployment.

Questionnaire Instructions

Please 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 skip any question that makes you feel uncomfortable without any penalty or prejudice.

Information you provide 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.

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

• 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 how to answer a question, please give the best answer you can.

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

• When you are finished, please place the questionnaire in the enclosed postage-paid envelope and put it in the mail. Please do not include your name.

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 45 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: FAMILY EXPERIENCES

1. What is your current marital status?

____Married

____Divorced

____In a romantic relationship and living as a couple

____In a romantic relationship but not living as a couple

____Widowed

____Separated

____Single/Never married

2. How many children do you have (both your own biological children and other children for whom you have parenting responsibilities)? ________ Number of children  If no children, Skip to 3, below

If you have children, what are their ages in years?

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

Child 6: _____ Child 7: ______ Child 8:_____ Child 9:_____ Child 10: _____

3. Who do you currently live with? (Mark all that apply)

____My husband, wife or other romantic partner

____My children or others for whom I have parenting responsibility

____My parents or in-laws

____Other relatives

____Other people who are not related to me

____No one else; I live alone

4. Where did you stay in the past 30 days? ( MARK ALL THAT APPLY)

____My own apartment or house

____Friend or relative’s apartment or house

____School or dormitory

____ Hospital or detox center

____Nursing home/assisted living

____Car or street

____Jail/prison

____Other (fill in) _________________________

The following set of statements is about your relationship with your family. Please note that these questions refer to whatever family you have, regardless of whether you are currently married/in a romantic relationship/have children. 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.

During the past 6 months:	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
My opinions are valued by other family members.	1	2	3	4	5
I am affectionate with family members.	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
I can be myself around family members.	1	2	3	4	5
I get along well with my family members.	1	2	3	4	5

SECTION B: ROMANTIC RELATIONSHIP EXPERIENCES

1. Have you had a spouse or other romantic partner at any point over the last six months? ____Yes  If yes, Skip to 3, below ____No

2. If not, why not? (Mark all that apply)
   ____I don’t want to be in a relationship right now.

____I want to be in a relationship but have not been able to find the right partner.

____I want to be in a relationship but do not have time to dedicate to a relationship

____Other _______________________________________

If you have not had a spouse or romantic partner at any point over the last six months, please continue to the next section (section c on p. 5). Otherwise, please answer the following questions:

3. How long have you been in your current romantic relationship?

____ years _____ months

During the past 6 months…	Never	Rarely	Occasionally	Sometimes	Often	Almost always	Always
When necessary, I cooperated on tasks with my spouse or partner.	1	2	3	4	5	6	7
I shared 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

Please indicate how many times you did each of these things in the past six months, and how many times your partner did them in the past six months.

To what extent do you agree that the following statements describe your romantic relationship overall over the past six months?	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
My partner meets my needs.	1	2	3	4	5
In general, I am satisfied with my relationship.	1	2	3	4	5
Compared to most relationships, my relationship is good.	1	2	3	4	5
I often wish I hadn’t gotten into this relationship.	1	2	3	4	5
My relationship has met my original expectations.	1	2	3	4	5
I love my partner	1	2	3	4	5
There are problems in my relationship.	1	2	3	4	5

How often did this happen in the past six months?	Once	Twice	3 -5 times	6 – 10 times	11 – 20 times	More than 20 times	Not in the past 6 months, but it did happen before	This has never happened
I insulted, swore, shouted 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 C: PARENTING

1. Are you a parent or have you served in a parenting role during the past six months (i.e., either to your own children or for other children)? ___Yes  If yes, Skip to 3, on page 6 ___ No

2. If you do not have children or have not served in a parenting role in the past six months, why not? (Mark all that apply)
   ____I don’t want to have children.

____I want to have children but am not ready yet

____I want to but I am not physically able to have children

____I want to have children but do not have time

____Other (please specify)_______________________________________

If you do not have children with whom you lived or had regular contact during the past six months, please continue to the next section (section d, on p. 7). Otherwise, please answer the following questions:

3. How long have you been in a parenting role?

____ years _____ months

Note that the term “my children” below refers to any children for whom you have parenting responsibilities.

Over the past six months…	Never	Rarely	Occasionally	Sometimes	Often	Almost always	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

During the past six months…	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
Being a parent has been an enjoyable experience.	1	2	3	4	5
2. I have been satisfied with the relationship I have 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 D: WORK EXPERIENCES

1. What is your current employment situation? (Mark all that apply)

____Employed

____Self-employed

____Working for pay full-time (30 hours or more a week)

____Working for pay part-time (less than 30 hours a week)

____Working at more than one job

____Working as volunteer (no pay)

____Not working but actively looking for work

____Not working and not looking for work

____Unable to work

____Temporarily laid off

____Maternity leave

____Illness/Sick leave

____Disabled

____Homemaker

____Student in high school, job training, or college degree program

____Retired

____Other (please specify)___________________________

2. Which of the following best describes your current or most recent employer? (Please mark one).

____Veterans Affairs (VA)

____A Federal Government organization other than the VA, including, Armed Forces

_____A State or Local Government organization, including public school teachers, firefighters, police officers, and other public servants)

____ A Public or Private, For Profit, Company

____ A Non-Profit Organization, including tax exempt and charitable organizations

____ Self-employed

____Other: (please describe)__________________________________________________

3a. What is your occupation? That is, what kind of work do you do? (For example: bookkeeper, plumber, teacher)?

________________________________________________________________________________________

3b. If you do not know your occupation, please describe your usual activities or responsibilities instead.

________________________________________________________________________________________

________________________________________________________________________________________

3. What is your job title? (This may be the same as the occupation listed above.)

________________________________________________________________________________________

3. What is your current salary or annual income?

____$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

3. Which of the following categories best describes your 2015 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

3. My current household income is enough to meet my financial needs.

____Strongly disagree

____Somewhat disagree

____Neither agree nor disagree

____Somewhat agree

____Strongly agree

3. Have you experienced periods during the past year when you wanted to work, or to work more hours, but couldn’t find work? ___Yes ___ No  If no, Skip to 12, below

8b. If you were unemployed, approximately how much time over the past year were you unemployed?

____Less than 1 month

____1-3 months

____4-6 months

____7-9 months

____10 months or longer

_____ Does not apply, I was employed in the last year

3. Have you worked for pay, as a volunteer, or as a homemaker at any point in the past six months?

____Yes ____No  If no, Skip to 12, below

9b. If yes, please select all that apply:

____Worked for pay

____Worked as volunteer

____Worked as a homemaker

3. If you have not worked for pay at some point in the past six months, why not? (Mark all that apply)
   
   

_____I have worked as a volunteer

_____I have worked as homemaker

_____I don’t want to work for pay.

_____I can’t find a job.

_____I have had trouble keeping a job.

_____The only job I can find is not right for me.

_____I am in school.

_____I am disabled.

_____Other (Please specify) _______________________________________

If you have not worked for pay, as a volunteer, or as a homemaker in the past six months, please continue to the next section (section e on p. 12). Otherwise, please answer the questions on the next page:

1. How many hours do you work in a typical work week? _______ hours

2. How long have you been in your present position? (If you have more than one job, please respond to this question with respect to your primary job)

____ years _____ months

3. How many days were you not able to work in the last four weeks? ______ days

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

5. On a scale from 0 to 10 where 0 is the worst job performance anyone could have in your position and 10 is the performance of a top worker, how would you rate the usual performance of most others in a position similar to yours? ____0 ____1 ____2 ____3 ____4 ____5 ____6 ____7 ____8 _____9 ____10

6. Using the same 0 – 10 scale, how would you rate your overall work performance when you were working during the past 4 weeks? ____0 ____1 ____2 ____3 ____4 ____5 ____6 ____7 ____8 _____9 ____10

If you have more than one job, please respond to the following questions with respect to your primary job.

During the past six months when you have been working, how much do you agree that the following adjectives have described your overall work experience?	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

During the past six months when you have been working, how much do you agree that the following statements have described your overall work experience?	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
My work requires less education than I have.	1	2	3	4	5
The work experience that I have is not necessary to be successful in this position.	1	2	3	4	5
I have job skills that are not required for this position.	1	2	3	4	5
Someone with less education than myself could perform well in my position.	1	2	3	4	5
My previous training is not being fully utilized in my work.	1	2	3	4	5
I have a lot of knowledge that I do not need in order to do my work.	1	2	3	4	5
My education level is above the education level required by my position.	1	2	3	4	5
Someone with less work experience than myself could do my work just as well.	1	2	3	4	5
I have more abilities than I need in order to do my work.	1	2	3	4	5

If you have not worked for pay in the past six months, please continue to the next section (Section e on p. 11). Otherwise, please answer the following questions:

During the past six months, how often have the following work experiences applied to you…	Never	Rarely	Occasionally	Sometimes	Often	Almost Always	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

During the past six months,	None of the time	A little of the time	Some of the time	Most of the time	All of the time
How often has your job or career interfered 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 has your job or career kept you from spending the amount of time you would like to spend with your family?	1	2	3	4	5
How often has your home life interfered 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 has your home life kept you from spending the amount of time you would like to spend on job- or career-related activities?	1	2	3	4	5

SECTION E: EDUCATION (INCLUDING DISTANCE LEARNING)

1. What is the highest grade or level of education you have completed? (Please mark 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. Have you been in school or taken classes (including distance learning) at any point in the past 6 months? __Yes __No  If no, Skip to 3, below

2a. If yes, please select all that apply: (Mark all that apply)

____Taking GED or other courses for high school completion

____Enrolled in trade school

____Not enrolled in undergraduate program but taking undergraduate classes

____Enrolled in undergraduate program full-time

____Enrolled in undergraduate program part-time

____Enrolled in graduate program full-time

____Enrolled in graduate program part-time

____Taking classes online

3. If you have not been in school in the last six months, why not? (Mark all that apply)

____No further education is necessary for my career.

____I don’t want to be in school.

____I want to be in school but am unable to afford it.

____I want to be in school but do not have time.

____I want to be in school but I struggle in school.

____I am disabled and unable to attend school.

____Other (Please specify) _______________________________________

If you have not been in school or taken classes (including distance learning) at any point in the past 6 months, please continue to the next section (SECTION F on p. 13). Otherwise, please answer the following questions:

1. How many hours do you spend in school or classes in a typical week? _______

2. 2. How long have you been in school or taking classes since you left military service?

____ years ____months

Over the past six months…	Never	Rarely	Occasionally	Sometimes	Often	Almost Always	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 was 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

Over the past six months…	None of the time	A little of the time	Some of the time	Most of the time	All of the time
How often has school interfered 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 has school kept you from spending the amount of time you would like to spend with your family?	1	2	3	4	5
How often has your home life interfered with your responsibilities at school, such as getting to class on time, accomplishing daily tasks, or completing assignments?	1	2	3	4	5
How often has your home life kept you from spending the amount of time you would like to spend on school-related activities?	1	2	3	4	5

SECTION F: DAY-TO-DAY ACTIVITIES

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

Over the past six months…	Never	Rarely	Occasionally	Sometimes	Often	Almost always	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 G: 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
During the past four weeks…	Not at all	A little bit	Moderately	Quite a bit	Extremely
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
12. Has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?	1	2	3	4	5	6

13. Over the past four weeks, how much sleep did you typically get each night? ____ hours

14. How much do you weigh? ____ pounds *If currently pregnant, please give your usual weight before

your pregnancy.

15. About how tall are you without shoes? __feet ___ inches

16. In the past week, on how many days have you done a total of 30 min or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job. __ days

SECTION H: SATISFACTION WITH LIFE

Below are five statements that you may agree or disagree with. Please mark how much you agree or disagree with each statement.

	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 I: 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

If you are currently experiencing suicidal thoughts, we recommend that you contact your primary care

provider and/or the Veterans Crisis Hotline (1-800-273-8255), who can provide assistance.

SECTION J: ALCOHOL & TOBACCO USE

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

1. 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. 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 to 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

4. Have you felt you ought to cut down on drinking? (Mark all that apply)

____No

____Yes, before my most recent military deployment

____Yes, at some time after my recent military deployment

____Yes, in the last 3 months

5. Have people annoyed you by criticizing your drinking? (Mark all that apply)

____No

____Yes, before my most recent military deployment

____Yes, at some time after my recent military deployment

____Yes, in the last 3 months

6. Have you felt bad or guilty about your drinking? (Mark all that apply)

____No

____Yes, before my most recent military deployment

____Yes, at some time after my recent military deployment

____Yes, in the last 3 months

7. Have you had a drink first thing in the morning to steady your nerves or get rid of a hangover (an “eye-opener”)? (Mark all that apply)

____No

____Yes, before my most recent military deployment

____Yes, at some time after my recent military deployment

____Yes, in the last 3 months

The following question relates to your use of tobacco products (cigarettes, smokeless tobacco, etc). Please mark the response corresponding to the most appropriate option.

8. Do you now use tobacco products (cigarettes, smokeless tobacco) every day, some days, or not at all. 

_____Every day

_____Some days

_____Not at all

SECTION K: POST-DEPLOYMENT DISTRESS

Please think about the event or events that were most disturbing to you during your most recent military deployment and respond to the statements about experiences or feelings you have had in the last three months. The worst event might be something that happened more than once. If so, you may want to think of all of the times together as the worst event. Please note that some of these items are similar to one another.

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 stressful military experience(s).	1	2	3	4	5
Repeated, disturbing dreams of my stressful military experience(s).	1	2	3	4	5
Suddenly acting or feeling as if my stressful military experience(s) were happening again.	1	2	3	4	5
Feeling very upset when something happened that reminded me of my stressful military experience(s).	1	2	3	4	5
Trouble remembering important parts of my stressful military experience(s).	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 stressful military experience(s).	1	2	3	4	5
Avoiding thinking about my stressful military experience(s), or avoid having feelings about them.	1	2	3	4	5
Avoiding activities or situations because they reminded me of my stressful military experience(s).	1	2	3	4	5
Repeated, disturbing, and unwanted memories of the stressful military experience(s).	1	2	3	4	5
Suddenly feeling or acting as if the stressful military experience(s) were actually happening again (as if I were actually back there reliving it).	1	2	3	4	5
Having strong physical reactions when something reminded me of the stressful military experience(s) (for example, heart pounding, trouble breathing, sweating).	1	2	3	4	5
Avoiding memories, thoughts, or feelings related to the stressful military experience(s).	1	2	3	4	5
Avoiding external reminders of the stressful military experience(s) (for example, people, places, conversations, activities, objects, or situations).	1	2	3	4	5
Trouble remembering important parts of the stressful military experience(s) (for some reason besides a head injury or alcohol or drug use).	1	2	3	4	5
Having strong negative beliefs about myself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous).	1	2	3	4	5
Blaming myself or someone else (who didn’t directly cause the event or actually harm me) for the stressful military experience(s) or what happened after it.	1	2	3	4	5
Having strong negative feelings such as fear, horror, anger, guilt, or shame.	1	2	3	4	5
Having trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to me).	1	2	3	4	5
Feeling irritable or angry or acting aggressively.	1	2	3	4	5
Taking too many risks or doing things that could cause me harm.	1	2	3	4	5

SECTION L: BELIEFS

Please rate the extent to which you agree or disagree with the following statements.

	Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
If I had a mental health problem and my friends and family knew about it, they would think less of me.	1	2	3	4	5
Seeking mental health treatment would make me think less of myself	1	2	3	4	5
Mental health treatment generally does not work	1	2	3	4	5
I can’t help but think less of people who have mental health problems.	1	2	3	4	5
If I had a mental health problem and people at work knew….
My coworkers would think I am not capable of doing my job.	1	2	3	4	5
A supervisor might treat me unfairly.	1	2	3	4	5
My career/job options would be limited.	1	2	3	4	5

SECTION M: SERVICE-CONNECTED DISABILITY

1. Which of the following describes your separation from military service? (Mark all that apply)

   1. ____Honorable

   2. ____General under honorable conditions

   3. ____Under another category besides honorable (e.g., Other Than Honorable (OTH), Bad Conduct Discharge (BCD), Dishonorable)

   4. ____Medical

   5. ____Not sure

2. Have you ever applied for VA disability benefits? ____Yes ____No (If no, please skip to Section N on p. 21)

1. If approved, what is your current percentage disability rating? ______%

2. If approved, what is your current disability rating related to your mental health? ______%

3. If approved, what is your current disability rating related to your physical health? ______%

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

4. Are you receiving any of the following: (Mark all that apply)

   1. ____Service-connected disability compensation

   2. ____Non-service-connected disability pension

   3. ____Anything else (Other, Please specify)_______________________________

5. Have you ever received regular monetary benefits from any other source due to your disability? ____Yes ____No  If no,Skip to Section N on p. 21

5a. If yes, from whom have you received these benefits? (Mark 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 N: USE OF HEALTH CARE BENEFITS AND SERVICES

1. Think about your use of health care since you left military service. Please check below whether you have used the following categories of care in either a VA or non-VA medical facility. Inpatient care refers to care that requires an overnight stay. Outpatient care refers to care that does not require an overnight stay.

	At VA Medical Facility or Paid for by VA	At Non-VA Medical Facility and not paid for by VA	I have not used this type of care since leaving military service
Urgent care for evaluation, medication, or counseling/therapy for a mental health problem
Urgent care for medical problems (e.g., emergency room visit)
Either inpatient or outpatient counseling/ therapy for posttraumatic stress disorder (PTSD)
Either inpatient or outpatient counseling/ therapy for depression or anxiety
Either inpatient or outpatient counseling/therapy for other mental health problems, including alcohol or drug abuse
Medication for PTSD
Medication for depression or anxiety
Medication for other mental health problem, including alcohol or drug abuse
Self-help or support group for a mental health problem
Preventative medical care (e.g., annual check-up)
Outpatient medical care for a medical problem
Inpatient medical care for a medical problem
Dental Care
In-home health care
Reproductive health/maternity care services

16. If you used VA health care, how satisfied were you with these services overall?

____Very dissatisfied

____ Somewhat dissatisfied

____ Neutral

____ Somewhat satisfied

____ Very satisfied

____ I did not use VA health care

17. What is the location (City, State) of the VA Medical Center or VA Community Based Outpatient Clinic (CBOC) that is closest to you? _______________city ____ _____ state ___ Don’t know

18. How long would you estimate that it would take you to get to this medical center or clinic? _______ hours _____ minutes

SECTION O: USE OF FAMILY SERVICES

The following questions are about your family’s use of family therapy or family consultation services, which often focus on improving skills involving communication, listening, and problem solving in the family, since you left military service .

1. Have you and your family come to the VA for a family consultation with a mental health professional on family problems (for example, managing PTSD symptoms or alcohol problems)?

____Yes ____No ____Don’t know

2. Have you and your family been referred to community family-focused programs or services by the VA?

____Yes ____No ____Don’t know

3. Have you and your family used non-VA family therapy or family consultation services?

____Yes ____No ____Don’t know

4. Have you and your spouse/partner come to the VA for group couples therapy (that is, with other couples)?

____Yes ____No ____Don’t know ____N/A (No spouse/partner)

5. Have you and your spouse/partner come to the VA for individual couples therapy (that is, just you and your partner)?

____Yes ____No ____Don’t know ____N/A (No spouse/partner)

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

1. Have you and your family attended VA family information sessions led by family member volunteers, such as the Family-to-Family Education Program?

____Yes ____No ____Don’t know

2. Have you and your family attended family information sessions led by VA mental health professionals, such as SAFE (Support and Family Education)?

____Yes ____No ____Don’t know

3. Have you and your family attended family information sessions outside of the VA?

____Yes ____No ____Don’t know

4. If you used VA family services of any kind, how satisfied were you were these services overall?

____Very dissatisfied

____ Somewhat dissatisfied

____ Neutral

____ Somewhat satisfied

____ Very satisfied

____ I did not use any VA family services

SECTION P: USE OF EDUCATIONAL AND EMPLOYMENT SERVICES/PROGRAMS

These next few questions ask about your use of education and training services or programs since you left military service.

1. Excluding vocational rehabilitation, have you used VA educational benefits to complete any of the activities below? (Check all that apply)

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

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

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

____Take correspondence courses

____Take flight training

____Get tutorial assistance, refresher courses, or deficiency training

____Attend a teacher certification program

____OTHER _____________________________________________________________)

____ I did not use any VA educational benefits

1a. If you used VA educational benefits to complete any of these activities, how satisfied were you with these benefits?

____Very dissatisfied

____ Somewhat dissatisfied

____ Neutral

____ Somewhat satisfied

____ Very satisfied

The next set of questions is about your use of employment services since you left military service.

2. Have you used the following VA employment or educational services or programs that are part of the VA’s Vocational Rehabilitation Program? (Mark 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

9. ____Other (please specify)______________________________________________________

10. ____ I did not use any VA employment or educational services/programs that are part of the VA’s Vocational Rehabilitation Program

3. Have you used any of the following VA services or programs as part of the VA’s Vocational Rehabilitation Program? (Mark all that apply)

____Vocational Rehabilitation and Employment (VR&E) Program (also known as Chapter 31)

____Veterans Employment and Training Service (VETS)

____Compensated Work Therapy (CWT)

____ I did not use any of the above VA services or programs

4. In the past 5 years, have you received other vocational rehabilitation services from any of the following other sources?

(Mark all that apply)

____State employment office

____State rehabilitation

____Disabled Veterans Outreach Program (DVOP)

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

____DoD, military, or TRICARE

____Other state or federal agency

____Other private insurance company

____ Other (Please specify)____________________________________________________

____ I have not used any other vocational rehabilitation services from other sources

5. Have you used any other employment assistance services or programs offered by VA, including web-based resources (e.g., Hero 2 Hired, My Next Move)? ____Yes ____No If no, Skip to 6, below

5b. If so, please briefly describe the program/service. __________________________________________________

6. Have you used any other non-VA employment assistance services or programs, including web-based resources? ____Yes ____No  If no, Skip to 7, below

6b. If so, please briefly describe the program/service. _______________________________________________

7. If you used VA employment programs and services of any kind, including vocational rehabilitation services, how satisfied were you with these services?

____Very dissatisfied

____ Somewhat dissatisfied

____ Neutral

____ Somewhat satisfied

____ Very satisfied

SECTION Q: RACE & ETHNICITY

1. How do you describe your race/ ethnicity? (Check all that apply)

____Native American or Alaska Native

____Black

____Asian

____Filipino

____West Asian/ Middle Eastern/ North African

____Hispanic/ Latino

____Native Hawaiian

____Other Pacific Islander (please specify): ________________________

____White/ European

____Other (please specify):________________________

2. With which race(s)/ ethnicity(ies) do you identify most? __________________

Do you give us permission to contact you in the future about the opportunity to participate in potential follow-up research studies? ____Yes _____No [Note: to be included in the T3 survey only]

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:

***INSERT NAME AND ADDRESS OF VENDOR***

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