VetSET Screening Tool

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1. Which county in Nebraska do you live?

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2. Have you ever served in the military? Are you an immediate family member of someone who has served in the military? (mark all that apply)

I served in the military

My husband, wife, or significant other served in the military

My child served in the military

My parent served in the military

My brother/sister served in the military

Other

Other (please specify)

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3. In which branch did you or your family member serve? (mark all that apply)

Army

Navy

Air Force

Marine Corps

Coast Guard

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4. Did you or your family member serve in...? (mark all that apply)

Active Duty

National Guard

Reserve

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5. Are you currently enrolled in the VA Health Care System?

Yes

Don't know

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6. In what era did you or your family member serve in the U.S. Armed Forces?

September 2001 or later (OEF/OIF/OND)

August 1990 to August 2001 (includes Persian Gulf War)

May 1975 to July 1990

Vietnam era (August 1964 to April 1975)

February 1955 to July 1964

Korean War (July 1950 to January 1955)

January 1947 to June 1949

World War II (December 1941 to December 1946)

November 1941 or earlier

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7. In our rural communities, what areas do you feel are the greatest needs for veterans and their families? (mark all that apply)

Health Care (excluding Mental Health)

Mental Health Services

Substance Abuse Programs

Education

Transportation

Employment/Job

Family support

Housing Assistance

Marital Counseling

Financial Management

Other (please specify)

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8. What is your gender?

Male

Female

VetSET Screening Tool

Question Title

1. Which county in Nebraska do you live?

Question Title

2. Have you ever served in the military? Are you an immediate family member of someone who has served in the military? (mark all that apply)

Question Title

3. In which branch did you or your family member serve? (mark all that apply)

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4. Did you or your family member serve in...? (mark all that apply)

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5. Are you currently enrolled in the VA Health Care System?

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6. In what era did you or your family member serve in the U.S. Armed Forces?

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7. In our rural communities, what areas do you feel are the greatest needs for veterans and their families? (mark all that apply)

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8. What is your gender?

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9. Age:

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10. Would you like someone from your local health department to contact you regarding obtaining additional resources or services?

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11. Name:

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12. Address:

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13. Contact Number:

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14. E-mail address

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15. For staff only. Data entered by:

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* 1. Which county in Nebraska do you live?

Question Title

* 2. Have you ever served in the military? Are you an immediate family member of someone who has served in the military? (mark all that apply)

Question Title

* 3. In which branch did you or your family member serve? (mark all that apply)

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* 4. Did you or your family member serve in...? (mark all that apply)

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* 5. Are you currently enrolled in the VA Health Care System?

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* 6. In what era did you or your family member serve in the U.S. Armed Forces?

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* 7. In our rural communities, what areas do you feel are the greatest needs for veterans and their families? (mark all that apply)

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* 8. What is your gender?

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* 9. Age:

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* 10. Would you like someone from your local health department to contact you regarding obtaining additional resources or services?

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* 11. Name:

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* 12. Address:

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* 13. Contact Number:

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* 14. E-mail address

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* 15. For staff only. Data entered by:

1. Which county in Nebraska do you live?

2. Have you ever served in the military? Are you an immediate family member of someone who has served in the military? (mark all that apply)

3. In which branch did you or your family member serve? (mark all that apply)

4. Did you or your family member serve in...? (mark all that apply)

5. Are you currently enrolled in the VA Health Care System?

6. In what era did you or your family member serve in the U.S. Armed Forces?

7. In our rural communities, what areas do you feel are the greatest needs for veterans and their families? (mark all that apply)

8. What is your gender?

9. Age:

10. Would you like someone from your local health department to contact you regarding obtaining additional resources or services?

11. Name:

12. Address:

13. Contact Number:

14. E-mail address

15. For staff only. Data entered by: