Because of a physical, mental, or emotional 13b. Have you ever been deployed to a combat condition, do you have difficulty doing errands zone [select all that apply]? alone—such as visiting a or doctor’s office shopping? Never deployed  Iraq or Afghanistan (e.g., Operation  Enduring Freedom/Operation Iraqi Yes  Freedom/Operation New Dawn) No  Persian Gulf (Operation Desert Shield  or Desert Storm) If you have ever been in juvenile/adult detention, Vietnam/Southeast Asia  jail, or prison for more than 3 days, how long Korea has it been since you last got out?  WWII  Deployed to a combat zone not listed above  Never in juvenile/adult detention, jail, or prison  (e.g., Somalia, Bosnia, Kosovo) for more than 3 days Less than two years  Is anyone in your family or someone close to Two years or more  you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or Have you ever served in the Armed Forces, in the retired from the Armed Forces, the Reserves, or Reserves, or the National Guard [select all that the National Guard? apply]? No (Skip to #16)  No (Skip to #14)  Yes, 1 person  Yes, in the Armed Forces  Yes, 2 people  Yes, in the Reserves  Yes, 3 people  Yes, in the National Guard  Yes, 4 people  Yes, 5 people  13a. Are you currently on active duty in the Yes, 6 or more people  Armed Forces, in the Reserves, or the National Guard? Yes, in the Armed Forces  Yes, in the Reserves  Yes, in the National Guard  No, separated or retired from Armed  Forces, Reserves, or National Guard If yes, answer the following questions for each person you marked in question 17 (up to six people). Service Service Service Service Service Service Member #1 Member #2 Member #3 Member #4 Member #5 Member #6 Service to you: member’s relationship Mother/father Brother/sister Spouse/partner Child Other, specify End of Section
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone—such as visiting a doctor’s office or shopping?  Yes  No If you have ever been in juvenile/adult detention, jail, or prison for more than 3 days, how long has it been since you last got out?  Never in juvenile/adult detention, jail, or prison for more than 3 days  Less than two years  Two years or more Have you ever served in the Armed Forces, in the Reserves, or the National Guard [select all that apply]?  No (Skip to #14)  Yes, in the Armed Forces  Yes, in the Reserves  Yes, in the National Guard 13a. Are you currently on active duty in the Armed Forces, in the Reserves, or the National Guard?  Yes, in the Armed Forces  Yes, in the Reserves  Yes, in the National Guard  No, separated or retired from Armed Forces, Reserves, or National Guard 13b. Have you ever been deployed to a combat zone [select all that apply]?  Never deployed  Iraq or Afghanistan (e.g., Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn)  Persian Gulf (Operation Desert Shield or Desert Storm)  Vietnam/Southeast Asia  Korea  WWII  Deployed to a combat zone not listed above (e.g., Somalia, Bosnia, Kosovo) Is anyone in your family or someone close to you on active duty in the Armed Forces, in the Reserves or the National Guard, or separated or retired from the Armed Forces, the Reserves, or the National Guard?  No (Skip to #16)  Yes, 1 person  Yes, 2 people  Yes, 3 people  Yes, 4 people  Yes, 5 people  Yes, 6 or more people If yes, answer the following questions for each person you marked in question 17 (up to six people). Service Member #1 Service Member #2 Service Member #3 Service Member #4 Service Member #5 Service Member #6 Service member’s relationship to you: Mother/father Brother/sister Spouse/partner Child Other, specify End of Section
adult-questionnaire.docx