Leader Survey

OMB CONTROL NUMBER: 0704-0610
OMB EXPIRATION DATE: 03/31/2025
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0704-0610, is estimated to
average 1.25 hours 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. Send comments regarding the burden estimate or burden reduction
suggestions to the Department of Defense, Washington Headquarters Services, at whs.mcalex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing
to comply with a collection of information if it does not display a currently valid OMB control
number.

Leader Survey

Please list your installation or ship name: ________________________

Instructions

The purpose of this survey is to assess the leader expertise needed to protect Service members’ health and
wellbeing and prevent Service members from dying by suicide; misusing alcohol; assaulting, harassing, or
bullying others; and engaging in interpersonal violence.
No one person is expected to have expertise in all areas; however, understanding your expertise can help
determine how you can best support the installation’s overall approach to promoting Service members’
health and wellbeing. For each item in the survey, you will be asked to rate how knowledgeable you are and
how relevant it is to your job or position. There are no right or wrong answers, please just answer based on
your experience.

Section 1: Healthy & Protective Environment

The first items are about the environment of the installation. Rate how knowledgeable you are about each
item from 1 (No knowledge) to 5 (Extensive knowledge/expertise) and how relevant each item is to your
job or position from 1 (Not relevant) to 5 (Central to my job or position).
1. Understand the environment’s role in causing or maintaining harmful behaviors such as harassment,
sexual assault, alcohol misuse, suicide, etc.
None
1
2
3
4
5
Extensive
Knowledge
〇
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〇
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Relevance
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2. Understand what actions and communications create an environment that is respectful for all members of the
unit.
None
1
2
3
4
5
Extensive
Knowledge
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〇
〇
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Relevance
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3. Understand how to help those who report to you create an environment that is respectful for all members of the
unit.
None
1
2
3
4
5
Extensive
Knowledge
〇
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〇
〇
〇
Relevance
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4. Understand how to ensure that a viable mechanism is in place for Service members to make
complaints of harassment and sexual assault
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
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5. Understand how to ensure that a viable mechanism is in place for Service members to report incidents
of substance abuse
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
〇
〇
〇
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6. Understand how to ensure that a viable mechanism is in place for Service members to report concerns
about suicide
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
〇
〇
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Continue on to next page

7. Understand how to establish regular (e.g., weekly) connection and communication with Service
members who report to you (e.g., holding office hours, walking around for meet and greets)
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
〇
〇
〇
〇
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8. Understand how to mentor and support the professional development of Service members who report
to you
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
〇
〇
〇
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9. Understand how to distribute resources (e.g., mental health care, childcare) to the Service members
that report to you in order to reduce stress and make their life better
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
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10. Understand how to evaluate the effectiveness of efforts to promote the health and wellbeing of Service
members and prevent suicide, alcohol misuse, sexual assault, harassment, and other harmful behaviors
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
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11. Understand how to apply these evaluation results to the performance evaluation of relevant Service
members who report to you
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
〇
Relevance
〇
〇
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Section 2: Integrated Prevention

The next section is about your knowledge of efforts to prevent Service members from dying by suicide;
misusing alcohol; assaulting, harassing, or bullying others; and engaging in interpersonal violence. Rate
how knowledgeable you are about each item from 1 (No knowledge) to 5 (Extensive knowledge/
expertise) and how relevant each item is to your job or position from 1 (Not relevant) to 5 (Central to my
job or position).
12. Understand the policies on prevention topics, including integrated primary prevention, harassment,
sexual assault, substance abuse, suicide, self-harm, etc.
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
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Relevance
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13. Understand the difference between prevention and response
Knowledge
Relevance

None

Continue on to next page

1

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2

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3

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4

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5

〇
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Extensive

14. Describe the influence of risk factors for suicide and harmful behaviors like alcohol misuse, domestic
violence, sexual assault, and harassment (e.g., general tolerance of harmful behaviors)
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
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Relevance
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15. Describe the influence of protective factors for suicide and harmful behaviors like alcohol misuse,
domestic violence, sexual assault, and harassment (e.g., emotional health, supportive leadership)
None
1
2
3
4
5
Extensive
Knowledge
〇
〇
〇
〇
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Relevance
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16. Understand the multiple key ingredients of effective evidence-based prevention (e.g., varied teaching
methods)
None
1
2
3
4
5
Extensive
Knowledge
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Relevance
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17. Know how to model standards and norms consistent with a professional organizational climate
None

1

2

3

4

5

Extensive

None

1

2

3

4

5

Extensive

None

1

2

3

4

5

Extensive

Knowledge
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Relevance
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18. Can recognize and account for risk and protective factors in special populations
Knowledge
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Relevance
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19. Understand how to use evaluation data to improve prevention efforts
Knowledge
Relevance

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Section 3: Service Member Engagement

The next section is about how Service members are involved in efforts to prevent Service members from
dying by suicide; misusing alcohol; assaulting, harassing, or bullying others; and engaging in
interpersonal violence. Rate how knowledgeable you are about each item from 1 (No knowledge) to 5
(Extensive knowledge/expertise) and how relevant each item is to your job or position from 1 (Not
relevant) to 5 (Central to my job or position).
20. Share information about ongoing prevention efforts with other Service members in a transparent and
consistent manner
None
1
2
3
4
5
Extensive
Knowledge
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〇
〇
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Relevance
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21. Convey what prevention efforts on your installation are trying to promote (e.g., safe and respectful
environments) in addition to what these efforts are trying to prevent (e.g., sexual assault)
None
1
2
3
4
5
Extensive
Knowledge
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Relevance
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Continue on to next page

22. Foster mutually respectful interactions between Service members and leadership at your installation
None

1

2

3

4

5

Extensive

Knowledge
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Relevance
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23. Work with Service members in such a way that they have meaningful input into decisions about
prevention activities
None
1
2
3
4
5
Extensive
Knowledge
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Relevance
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Section 4: Demographics

Below are a few questions about your background. This information is used to help characterize the group
of individuals responding to this survey and will not impact your anonymity.
24. Age
25. Sex

〇

〇

Man
26. Hispanic

27. Service
28. Component

Woman

〇

〇

Yes

No

〇

〇

Air Force
〇

Active

Army
〇

Natl Guard

29. Paygrade (select one)
E1-E4
〇
E5-E6
〇
E7-E9
〇
O1-O3
〇
O4-O6 or above
〇
W1-W3
〇
W4-W5
〇
Prefer not to
〇
respond
GS, fill in
number:

〇

Prefer not to
respond
〇

Prefer not to
respond
〇

Navy
〇

Reserve

〇

Marine Corps
〇

DoD Civilian
30. Education
Some HS
HS Diploma/GED
Some college/no degree
2 yr. college
4 yr. college
> 4 yr. college
Prefer not to respond

Other; please describe: _____________________

Continue on to next page

〇

Space Force
〇

N/A

〇
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〇

N/A

31. Race/Ethnicity

Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of
Barrow lnupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.

D Asian -

Provide details below.

□ Chinese
□ Vietnamese

□ Asian Indian
□ Korean

Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

D Black or African American African American

Provide details below.

□ Jamaican

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

D Hispanic or Latino Mexican

Cuban

Provide details below.

□ Puerto Rican
□ Dominican

□ Salvadoran
□ Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

D Middle Eastern or North African Lebanese

Syrian

□ Iranian
□ Iraqi

Provide details below.

□ Egyptian
□ Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

Native Hawaiian
Tongan

□ Samoan

Enter, for example, Chuukese, Palauan, Tahitian, etc.

D White -

Provide details below.

English

Italian

□ German
□ Polish

□ Irish
□ Scottish

Enter, for example, French, Swedish, Norwegian, etc.

Thank you!
Continue on to next page