My military branch of service is:
Army Navy Air force Marine Corps Coast Guard Merchant Marines Reserves National Guard
My rank or equivalent is:
E1-E4 E5-E9 CW1-CW2 CW3-CW5 O1-O3 O4-O6 O7-O10
My length of military service is/was:
Less than 2 years 2-4 years 5-9 years 10-14 years 15+
How many times have you been deployed overseas in past 8 years?
What is your highest education level completed?
Less than high school
High school/GED
Post high school training
Bachelors degree
Graduate degree
What was your annual household gross income before deployment?
Below $15,000 15,000-24,999 25,000-49,999 50,000-99,999 100,000-200,000 $200,000+
What is your annual household gross income now?
Below $15,000 15,000-24,999 25,000-49,999 50,000-99,999 100,000-200,000 $200,000+
Were you employed at time of deployment?
Yes No
Please describe the industry that best describes your employer.
How long were you employed with your employer?
How many hours on average did you work weekly?
Less than 15 hrs 15-30 hrs 30+ (full time)
When returning from deployment did you return to the same pre-deployment job?
Yes No
If no, what was your primary reason?
Job no longer available (company eliminated position, downsized, etc.)
Returned to school
Decided to change career/profession
Received a better job from another company
Did not feel supported by employer and decided not to go back
Family circumstances (death in family, etc.)
Relocated
Unable to work due to disability sustained during deployment
Other (explain)
If you selected "other" reasons for not having returned to the same employer, explain the reason.
Employed Self-employed Unemployed Seeking employment A student Retired
If employed what is your job?
How many hours on average do you work weekly?
Less than 15 hrs 15-30 hrs 30+ (full time)
female male
White/Caucasian Black / African American American Indian / Alaska Native Asian Native Hawaiian Other Pacific Islander Hispanic / Mexican Other
If you selected "other" as your race, enter your race:
Married Divorced Widowed Separated Single Partnered
Yes No
Rural community Urban community
The State in which I live is:
A medically diagnosed, recognized disability I do not have a disability I believe I have a disability that has not been diagnosed
Service connected Non-service connected Both service and non-service connected N/A
My disability is (select all that apply):
If you selected "other" as the type of your disability, write your disability:
Select what support services you have used:
If you selected "other" for support services that you have received, write the support that you have received:
Select what support services you need:
If you selected "other" for supports that you need now, write the supports that you need:
Alcohol (for women, 4 or more drinks in a day; for men 5 or more drinks in a day.)
Never Once or Twice Monthly Weekly Daily or Almost Daily
Never Once or Twice Monthly Weekly Daily or Almost Daily
Prescription Drugs for Non-medical Reasons
Never Once or Twice Monthly Weekly Daily or Almost Daily
Never Once or Twice Monthly Weekly Daily or Almost Daily
In the past 30 days how often have you gambled (lottery, casino, online gambling, sports betting, slot machines/video poker):
never 1-2 days 3-5 days 6-9 days 10-19 days 20-29 days used daily
During the past 12 months, did you ever seriously consider attempting suicide?
Yes No
Did you ever go on combat patrols or have other dangerous duty?
No 1-3X 4-12X 13-50X 51+times
Were you ever under enemy fire?
Never < 1 month 1 - 3 months 4 - 6 months 7 mos or more
Were you ever surrounded by the enemy?
No 1-2X 3-12X 13-25X 26+times
What percentage of the soldiers in your unit were killed (KIA), wounded or missing in action (MIA)?
None 1-25% 26-50% 51-75% 76% or more
How often did you fire rounds at the enemy?
Never 1-2X 3-12X 13-50X 51+times
How often were you in danger of being injured or killed (i.e., being pinned down, overrun, ambushed, near miss, etc.)?
Never 1-2X 3-12X 13-50X 51+times
How often did you see someone hit by incoming or outgoing rounds?
Never 1-2X 3-12X 13-50X 51+times
Any reminder brought back feelings about it.
Not at all A little bit Moderately Quite a bit Extremely
I had trouble staying asleep.
Not at all A little bit Moderately Quite a bit Extremely
Other things kept making me think about it.
Not at all A little bit Moderately Quite a bit Extremely
I felt irritable and angry.
Not at all A little bit Moderately Quite a bit Extremely
I avoided letting myself get upset when I thought about it or was reminded of it.
Not at all A little bit Moderately Quite a bit Extremely
I thought about it when I didn't mean to.
Not at all A little bit Moderately Quite a bit Extremely
I felt as if it hadn't happened or wasn't real.
Not at all A little bit Moderately Quite a bit Extremely
I stayed away from reminders about it.
Not at all A little bit Moderately Quite a bit Extremely
Pictures about it popped into my mind.
Not at all A little bit Moderately Quite a bit Extremely
I was jumpy and easily startled.
Not at all A little bit Moderately Quite a bit Extremely
I tried not to think about it.
Not at all A little bit Moderately Quite a bit Extremely
I was aware that I still had a lot of feelings about it, but I didn't deal with them.
Not at all A little bit Moderately Quite a bit Extremely
My feelings about it were kind of numb.
Not at all A little bit Moderately Quite a bit Extremely
I found myself acting or feeling like I was back at that time.
Not at all A little bit Moderately Quite a bit Extremely
I had trouble falling asleep.
Not at all A little bit Moderately Quite a bit Extremely
I had waves of strong feelings about it.
Not at all A little bit Moderately Quite a bit Extremely
I tried to remove it from my memory.
Not at all A little bit Moderately Quite a bit Extremely
I had trouble concentrating.
Not at all A little bit Moderately Quite a bit Extremely
Reminders of it caused me to have physical reactions, such as sweating, trouble berating, nausea, or a pounding heat.
Not at all A little bit Moderately Quite a bit Extremely
Not at all A little bit Moderately Quite a bit Extremely
I felt watchful and on guard.
Not at all A little bit Moderately Quite a bit Extremely
I tried not to talk about it.
Not at all A little bit Moderately Quite a bit Extremely
I am able to adapt when changes occur.
not true at all rarely true sometimes true often true true nearly all the time
I have at least one close and secure relationship that helps me when I am stressed.
not true at all rarely true sometimes true often true true nearly all the time
When there are no clear solutions to my problems, sometimes fate or God can help
not true at all rarely true sometimes true often true true nearly all the time
I can deal with whatever comes my way.
not true at all rarely true sometimes true often true true nearly all the time
Past successes give me confidence in dealing with new challenges and difficulties.
not true at all rarely true sometimes true often true true nearly all the time
I try to see the humorous side of things when I am faced with problems.
not true at all rarely true sometimes true often true true nearly all the time
Having to cope with stress can make me stronger.
not true at all rarely true sometimes true often true true nearly all the time
I tend to bounce back after illness, injury, or other hardships.
not true at all rarely true sometimes true often true true nearly all the time
Good or bad, I believe that most things happen for a reason.
not true at all rarely true sometimes true often true true nearly all the time
I give my best effort no matter what the outcome may be.
not true at all rarely true sometimes true often true true nearly all the time
I believe I can achieve my goals, even if there are obstacles.
not true at all rarely true sometimes true often true true nearly all the time
Even when things look hopeless, I don't give up.
not true at all rarely true sometimes true often true true nearly all the time
During times of stress/crisis, I know where to turn for help.
not true at all rarely true sometimes true often true true nearly all the time
Under pressure, I stay focused and think clearly.
not true at all rarely true sometimes true often true true nearly all the time
I prefer to take the lead in solving problems rather than letting others make all the decisions.
not true at all rarely true sometimes true often true true nearly all the time
I am not easily discouraged by failure.
not true at all rarely true sometimes true often true true nearly all the time
I think of myself as a strong person when dealing with life's challenges and difficulties.
not true at all rarely true sometimes true often true true nearly all the time
I can make unpopular or difficult decisions that affect other people, if it is necessary.
not true at all rarely true sometimes true often true true nearly all the time
I am able to handle unpleasant or painful feelings like sadness, fear, and anger.
not true at all rarely true sometimes true often true true nearly all the time
In dealing with life's problems, sometimes you have to act on a hunch without knowing why
not true at all rarely true sometimes true often true true nearly all the time
I have a strong sense of purpose in life.
not true at all rarely true sometimes true often true true nearly all the time
I feel in control of my life.
not true at all rarely true sometimes true often true true nearly all the time
not true at all rarely true sometimes true often true true nearly all the time
I work to attain my goals no matter what roadblocks I encounter along the way.
not true at all rarely true sometimes true often true true nearly all the time
I take pride in my achievements.
not true at all rarely true sometimes true often true true nearly all the time
How satisfied are you at this time with material comforts home, food, conveniences, financial security?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your health - being physically fit and vigorous.
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your relationships with parents, siblings & other relatives- communicating, visiting, helping.
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your having and rearing children?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your close relationships with spouse or significant other?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your close friends?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your helping and encouraging others, volunteering, giving advice?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your participation in organizations and public affairs?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your learning- attending school, improving understanding, getting additional knowledge?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with understanding yourself - knowing your assets and limitations - knowing what life is about?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your work - job or in home?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with expressing yourself creatively?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your socializing - meeting other people, doing things, parties, etc.?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with your reading, listening to music, or observing entertainment?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with participating in active recreation?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
How satisfied are you at this time with independence, doing for yourself?
Delighted Mostly Pleased Satisfied Mixed Dissatisfied Mostly Unhappy Terrible
Thank you for your time. You have now completed the assessment. Please push submit.