Veteran 2011 Services
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1
. What years did you serve?
MM
DD
YYYY
Starting
What years did you serve? Starting Month
/
Day
/
Year
Ending
Ending Month
/
Day
/
Year
2
. What is your gender?
What is your gender?
Male
Female
3
. Are you currently utilizing veteran services?
Are you currently utilizing veteran services?
Yes
No
4
. If so which ones?
If so which ones?
5
. Do you feel that the following services are available to you in a reachable way? On a scale of 1 to 5 with 1 being the least available and 5 being the most available.
1
2
3
4
5
N/A
Disabled
*
Do you feel that the following services are available to you in a reachable way? On a scale of 1 to 5 with 1 being the least available and 5 being the most available. Disabled 1
Disabled 2
Disabled 3
Disabled 4
Disabled 5
Disabled N/A
Vocational Rehabilitation
Vocational Rehabilitation 1
Vocational Rehabilitation 2
Vocational Rehabilitation 3
Vocational Rehabilitation 4
Vocational Rehabilitation 5
Vocational Rehabilitation N/A
Monetary Benefits
Monetary Benefits 1
Monetary Benefits 2
Monetary Benefits 3
Monetary Benefits 4
Monetary Benefits 5
Monetary Benefits N/A
Physical Health
Physical Health 1
Physical Health 2
Physical Health 3
Physical Health 4
Physical Health 5
Physical Health N/A
Mental Health
Mental Health 1
Mental Health 2
Mental Health 3
Mental Health 4
Mental Health 5
Mental Health N/A
Housing
Housing 1
Housing 2
Housing 3
Housing 4
Housing 5
Housing N/A
Education
Education 1
Education 2
Education 3
Education 4
Education 5
Education N/A
Employment
Employment 1
Employment 2
Employment 3
Employment 4
Employment 5
Employment N/A
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