Which county in Nebraska do you live?

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* 1. Which county in Nebraska do you live?

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)

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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)

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

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

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

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

Are you currently enrolled in the VA Health Care System?

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

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

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

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

What is your gender?

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* 8. What is your gender?

Age:

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* 9. Age:

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

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

Name:

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* 11. Name:

Address:

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* 12. Address:

Contact Number:

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* 13. Contact Number:

E-mail address

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* 14. E-mail address

For staff only. Data entered by:

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* 15. For staff only. Data entered by:

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