Year Separated from Military Service: ____________________ Branch of the Military:  Army  Air Force  Navy  Marines  Coast Guard  Client Doesn’t Know  Client Refused Discharge Status:  Honorable  General under honorable conditions  Under other than honorable conditions  Dishonorable  Uncharacterized  Client Doesn’t Know  Client Refused Theatre of Operations: World War II Yes No Client Doesn’t Know Client Refused     Korean War Yes No Client Doesn’t Know Client Refused     Vietnam War Yes No Client Doesn’t Know Client Refused     Persian Gulf War (Operation Desert Storm) Yes No Client Doesn’t Know Client Refused     Afghanistan (Operation Enduring Freedom) Yes No Client Doesn’t Know Client Refused     Iraq (Operation Iraqi Freedom) Yes No Client Doesn’t Know Client Refused     Iraq (Operation New Dawn) Yes No Client Doesn’t Know Client Refused     Other Peace-keeping Operations or Military Interventions Yes No Client Doesn’t Know Client Refused     (such as Lebanon, Panama, Somalia, Bosnia, Kosovo) Percent of AMI:  Less than 30%  30% to 50%  Greater than 50% Last Permanent Address: Street Address___________________________ City ______________________ State ________ Zip Code _______________ Last Permanent Address Data Quality:  Full Address Reported  Incomplete or Estimated Address Reported  Client Doesn’t Know  Client Refused  Data Not Collected Last Grade Completed:  Less than Grade 5  Grades 5-6  Grades 7-8  Grades 9-11  Grade 12  School program does not have grade levels  GED  Some College  Associate Degree  Bachelor’s Degree  Graduate Degree  Vocational Certification  Client Doesn’t Know Client Refused Data Not Collected   VAMC Station Number: __________________ Number of Visits to Emergency Room in the Past Year:  0  1-2 3-5 6-10 11-20 more than 20      Client Doesn’t Know  Client Refused  Data Not Collected
Year Separated from Military Service: ____________________ Branch of the Military:  Army  Air Force  Navy  Marines  Coast Guard  Client Doesn’t Know  Client Refused Discharge Status:  Honorable  General under honorable conditions  Under other than honorable conditions  Dishonorable  Uncharacterized  Client Doesn’t Know  Client Refused Theatre of Operations: World War II  Yes  No  Client Doesn’t Know  Client Refused Korean War  Yes  No  Client Doesn’t Know  Client Refused Vietnam War  Yes  No  Client Doesn’t Know  Client Refused Persian Gulf War (Operation Desert Storm)  Yes  No  Client Doesn’t Know  Client Refused Afghanistan (Operation Enduring Freedom)  Yes  No  Client Doesn’t Know  Client Refused Iraq (Operation Iraqi Freedom)  Yes  No  Client Doesn’t Know  Client Refused Iraq (Operation New Dawn)  Yes  No  Client Doesn’t Know  Client Refused Other Peace-keeping Operations or Military Interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo)  Yes  No  Client Doesn’t Know  Client Refused Percent of AMI:  Less than 30%  30% to 50%  Greater than 50% Last Permanent Address: Street Address___________________________ City ______________________ State ________ Zip Code _______________ Last Permanent Address Data Quality:  Full Address Reported  Incomplete or Estimated Address Reported  Client Doesn’t Know  Client Refused  Data Not Collected Last Grade Completed:  Less than Grade 5  Grades 5-6  Grades 7-8  Grades 9-11  Grade 12  School program does not have grade levels  GED  Some College  Associate Degree  Bachelor’s Degree  Graduate Degree  Vocational Certification  Client Doesn’t Know  Client Refused  Data Not Collected VAMC Station Number: __________________ Number of Visits to Emergency Room in the Past Year:  0  1-2  3-5  6-10  11-20  more than 20  Client Doesn’t Know  Client Refused  Data Not Collected
ssvf-entry-20161.docx