* 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:

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