Appendix C

Airborne Hazards and Open Burn Pit Registry Self-Assessment Questionnaire

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Airborne Hazards and Open Burn Pit Registry Self-Assessment Questionnaire

Contents

1. Deployment History

1.1. Deployment Data from the VA Defense Information Repository (VADIR) and DMDC

1.2. Location Specific Deployment Exposures

1.3. General Military Occupational Exposures

1.4. Environmental Exposures, Regional Air Pollution

2. Symptoms and Medical History

2.1. Functional Limitations and Reported Cause

2.2. Health Conditions

2.2.1. Respiratory Conditions

2.2.2. Cardiovascular Conditions

2.2.3. Other Conditions

2.3. Height and Weight

2.4. Cancer History

2.5. Tobacco Exposure

2.6. Deployment Smoking History

2.7. 12 Month Alcohol Use

3. Health Concerns

4. Places You’ve Lived

5. Work History

5.1. Current Occupational Status

5.2. Main Occupation

5.3. Dust Exposures

5.4. Gas, Smoke, Vapors or Fumes Exposures

5.5. Asbestos Exposure

6. Home Environment and Hobbies

7. Health Care Utilization

8. Contact Preferences

Note: items in square parenthesis, “[]”, and item selection number are not displayed to the user.

1. Deployment History

1.1. Deployment Data from the VA Defense Information Repository (VADIR) and DMDC

[Note: Deployment and demographic data will be obtained from DoD data sources (VADIR) after the user’s personal identifier is authenticated and stored in the registry database. All deployments from DoD data are displayed to the user. The user will then indicate if the deployment dates are valid or not, add missing deployments, and select which base names they were at while deployed. Guidance will be provided to facilitate direct contact with the appropriate DoD service to correct entries in the official system of record for the DoD deployment data.]

1.2. Location Specific Deployment Exposures

“Tell us about potential exposures while you were deployed.”

[Note: Section 1.2 questions are asked for each deployment or deployment segment in the VADIR data]

“During this deployment or portion of your deployment:”

1. [if deployment dates within 1990 – 1992, e.g. VADIR GWVIS indicator set], Were you exposed to soot, ash, smoke, or fumes from the Gulf War oil well fires?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

2. Where did you spend most of your time during these dates?

   [if deployment dates not within 1990 – 1992, e.g. VADIR GWVIS indicator not set:list base names, see Appendix A]

   [Select from list], Other (text entry), I do not wish to answer, Don’t know

3. If you were at more than one base, where did you spend the second most amount of time during these dates?

   [if deployment dates not within 1990 – 1992, e.g. VADIR GWVIS indicator not set: list base names, see Appendix A]

   [Select from list], Other (text entry), I was not at any other bases, I do not wish to answer, Don’t know

4. Were you near a burn pit during these dates (on the base or close enough to the base for you to see the smoke)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

5. [If ‘D’ = yes], Who ran this burn pit (circle all that apply)?

   1. U.S. forces or Contractor, 2. Coalition forces, 3. Host nation, 4. I do not wish to answer, 5. Don’t know

6. [If ‘D’ = yes] Did your duties during these dates include the burn pit (examples include trash burning, hauling trash to the burn pit, burn pit security, trash sorting at the burn pit)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

7. [If ‘D’ = yes] On a typical day, how many hours did smoke or fumes from the burn pit enter your work site or housing?

   1. Never, 2. Enter {1, 2, 3, … 24} hours, 3. I do not wish to answer, 4. Don’t know

8. On a typical day, how many hours were you outside or in an open tent or shelter (for example a single wall tent with open seams or drafty “B” hut)?

   1. Never, 2. Enter {1, 2, 3, … 24} hours, 3. I do not wish to answer, 4. Don’t know

9. On a typical day, how many hours were you near (for example you could smell or see it) sewage ponds?

   1. Never, 2. Enter {1, 2, 3, … 24} hours, 3. I do not wish to answer, 4. Don’t know

1.3. General Military Occupational Exposures

During any of your deployments:

1. Were you ever close enough to feel the blast from an IED (improvised explosive device) or other explosive device?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know
2. In a typical month, how many days were you near heavy smoke from weapons, signal smoke, markers, or other combat items?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
3. In a typical month, how many days were you in convoy or other vehicle operations?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
4. In a typical month, how many days did you perform refueling operations?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
5. In a typical month, how many days did you perform aircraft, generator, or other large engine maintenance?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
6. In a typical month, how many days did you perform construction duties?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
7. In a typical month, how many days did you perform pesticide duties for your unit?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know

1.4. Environmental Exposures, Regional Air Pollution

1. Did you do anything differently during your deployment(s), when you thought or were informed air quality was bad (for example during dust storms or heavy pollution days)?

   1. Yes, 2. No, 3. Never thought of this, 4. I was not informed or aware of bad air quality, 5. I do not wish to answer, 6. Don’t know

2. [A=yes], What did you do differently (select all that apply)?
   1. Wore a mask, cravat, or bandana over your mouth or nose
   2. Spent less time outdoors
   3. Did less strenuous activities (i.e. avoided physical training (PT))
   4. Took medication

3. 5. Closed windows of your sleeping quarters
   6. Spent less time in convoy
   7. Canceled outdoor activities
   8. Exercised indoors instead of outdoors
   9. Used or changed air filter/air cleaner
   10. Other
   11. I did not (or could not) do anything differently
   12. I do not wish to answer
4. In a typical month during your deployment(s), how many days did you experience dust storms?
   1. Never, 2. Enter {1, 2, 3 … 31} days, 3. I do not wish to answer, 4. Don’t know
5. During your deployment(s), did you experience wheezing, difficulty breathing, an itchy or irritated nose, eyes or throat that you thought was the result of poor air quality?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know
6. [If ‘D’=yes], How many days in an average month did you experience wheezing, difficulty breathing, an itchy or irritated eyes, nose or throat that you thought was the result of poor air quality?
   1. Enter {1, 2, 3 … 31} days, 2. Never, 3. I do not wish to answer, 4. Don’t know
7. During your deployment(s), did you seek medical care for wheezing, difficulty breathing, itchy or irritated nose, eyes or throat that you thought was the result of poor air quality?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

2. Symptoms and Medical History

“Tell us your health history. Please list all conditions even if you don’t think they’re related to a deployment exposure.”

2.1. Functional Limitations and Reported Cause

[Source: NHIS Adult Health Status & Limitations starting with AHS.091_01.000]

1. How difficult is it to run or jog one mile on a level surface?

2. 1. Not at all difficult, 2. only a little difficult, 3. somewhat difficult, 4. very difficult, 5. can’t do it at all, 6. do not do this activity, 7. I do not wish to answer,

   8. Don’t know

3. How difficult is it to walk on a level surface for one mile?

   1. Not at all difficult, 2. only a little difficult, 3. somewhat difficult, 4. very difficult, 5. can’t do it at all, 6. do not do this activity, 7. I do not wish to answer,

   8. Don’t know

4. How difficult is it to walk a ¼ of a mile – about 3 city blocks?

   1. Not at all difficult, 2. only a little difficult, 3. somewhat difficult, 4. very difficult, 5. can’t do it at all, 6. do not do this activity, 7. I do not wish to answer,

   8. Don’t know

5. How difficult is it to walk up a hill or incline?

   1. Not at all difficult, 2. only a little difficult, 3. somewhat difficult, 4. very difficult, 5. can’t do it at all, 6. do not do this activity, 7. I do not wish to answer,

   8. Don’t know

6. How difficult is it to walk up 10 steps or climb a flight of stairs?

   1. Not at all difficult, 2. only a little difficult, 3. somewhat difficult, 4. very difficult, 5. can’t do it at all, 6. do not do this activity, 7. I do not wish to answer,

   8. Don’t know

   [Source: NHIS: Adult Health Status & Limitations AHS.200_00.000, selection 14 modified]

7. [If any question A-E = “difficult”] What condition or health problem causes you to have difficulty with these activities? (Check all that apply.)

   01 Arthritis/rheumatism

   02 Back or neck problem

   03 Benign Tumors, Cysts

   04 Birth defect

   05 Brain injury (for example, Traumatic Brain Injury/TBI, Intellectual disability)

   06 Cancer

   07 Circulation problems (including blood clots)

   08 Depression/anxiety/emotional problem

   9 Diabetes

   10 Epilepsy, seizures

   11 Fibromyalgia, lupus

   12 Fracture, bone/joint injury

   13 Hearing problem

   14 Heart problem

   15 Hernia

1. 16 Hypertension/high blood pressure

   17 Kidney, bladder or renal problems

   18 Knee problems (not arthritis, not joint injury)

   19 Lung/breathing problem (for example, asthma and emphysema)

   20 Migraine headaches (not just headaches)

   21 Missing limbs (fingers, toes or digits), amputee

   22 Multiple Sclerosis (MS), Muscular Dystrophy (MD)

   23 Other developmental problem (for example, cerebral palsy)

   24 Other injury

   25 Other nerve damage, including carpal tunnel syndrome

   26 Osteoporosis, tendinitis

   27 Parkinson’s disease, other tremors

   28 Polio(myelitis), paralysis, para/quadriplegia

   29 Senility

   30 Stroke problem

   31 Thyroid problems, Grave’s disease, gout

   32 Ulcer

   33 Varicose veins, hemorrhoids

   34 Vision/problem seeing

   35 Weight problem

   36 Other impairment/problem (Specify one)

   37 I do not wish to answer

   38 Don’t know/Not sure

2.2. Health Conditions

2.2.1. Respiratory Conditions

[Source: NHIS Adult Conditions ACN.031 series]

1. Have you ever been told by a doctor or other health professional that you had Hay fever or allergies to pollen, dust, or animals?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [Source: NHIS Adult Conditions ACN.080_00.000]

2. Have you ever been told by a doctor or other health care professional that you had asthma?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

3. Have you ever been told by a doctor or other health care professional that you had emphysema?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

4. Have you ever been told by a doctor or other health care professional that you had chronic bronchitis?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [Source: NHIS Adult Conditions ACN.035 series]

5. Have you ever been told by a doctor or other health care professional that you had chronic obstructive pulmonary disease also called COPD?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

6. Have you ever been told by a doctor or other health care professional that you had some lung disease or condition other than asthma, emphysema, chronic bronchitis or COPD?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

7. [if F=“Yes”] Have you ever been told by a doctor or other health care professional that you had constrictive bronchiolitis (CB)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

8. [if F=“Yes”] Have you ever been told by a doctor or other health care professional that you had pulmonary fibrosis or idiopathic pulmonary fibrosis (IPF)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

9. [if B-F = yes], When you were told you had asthma, emphysema, chronic bronchitis, COPD or some other lung disease by a doctor or other health care professional, were you told before, during, or after deployment? (check all that apply.)

   1. Before deployment, 2. During deployment, 3. After deployment, 4. I do not wish to answer, 5. Don’t know

10. [if I = Before], Did this lung disease get better, worse, or about the same during deployment?

    1. Better, 2. Worse, 3. About the Same, 4. Not applicable, 5. I do not wish to answer, 6. Don’t know

11. Do you currently have any of the following symptoms? (Check all that apply.)

    1. Cough for more than 3 weeks

    2. Sputum or phlegm production for more than 3 weeks

    3. Wheezing or whistling in the chest

12. 4. Shortness of breath; breathlessness

    5. Decreased ability to exercise

    6. Hay fever or other respiratory allergy

    7. Sore throat, hoarseness, or change in voice

    8. Chest pain, chest discomfort or chest tightness

    9. Chronic sinus infection/sinusitis

    10. I do not wish to answer

    11. I do not have these symptoms

13. In the past 12 months did you have any of the following symptoms? (Check all that apply.)

    1. Cough for more than 3 weeks

    2. Sputum or phlegm production for more than 3 weeks

    3. Wheezing or whistling in the chest

    4. Shortness of breath; breathlessness

    5. Decreased ability to exercise

    6. Hay fever or other respiratory allergy

    7. Sore throat, hoarseness, or change in voice

    8. Chest pain, chest discomfort or chest tightness

    9. Chronic sinus infection/sinusitis

    10. I do not wish to answer

    11. I do not have these symptoms

    [Source: Medical Research Chronic (MRC) Breathlessness scale]

14. [IF ANSWER TO “L” Current Health symptoms = 04] How would you rate your shortness of breath or breathlessness? (Check the description/grade that applies to you.) I’m:

    1. Not troubled by breathlessness except on strenuous exercise

    2. Short of breath when hurrying on the level or walking up a slight hill

    3. Walking slower than most people on level ground, stop after one mile, or stop after 15 minutes walking at my own pace

    4. Stopping for breath after walking about 100 yards or after a few minutes on level ground

    5. Too breathless to leave the house, or breathless when dressing or undressing

    6. I do not wish to answer

2.2.2. Cardiovascular Conditions

1. Have you ever been told by a doctor or other health care professional that you had hypertension, also called high blood pressure?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

2. Have you ever been told by a doctor or other health care professional that you had coronary artery disease?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

3. Have you ever been told by a doctor or other health care professional that you had angina pectoris?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

4. Have you ever been told by a doctor or other health care professional that you had a heart attack, also called myocardial infarction?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

5. Have you ever been told by a doctor or other health care professional that you had a heart condition other than coronary artery disease or angina or myocardial infarction?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

6. [if any A-E = yes], When you were told you had hypertension, coronary artery disease, angina pectoris, a heart attack, or some other heart condition by a doctor or other health care professional, were you told before, during, or after deployment? (check all that apply.)

   1. Before deployment, 2. During deployment, 3. After deployment, 4. I do not wish to answer, 5. Don’t know

2.2.3. Other Conditions

[Source NHIS ACN.125_00.250]

1. During the past 12 months, have you regularly had insomnia or trouble sleeping?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [Source modified from NHIS ACN.125_00.130]

2. During the past 12 months, have you had Neurological problems? (Some examples of neurological problems may include numbness, tingling, or weakness in your arms or legs or difficulties with thinking or memory.)

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [Source modified from NHIS ACN.125_00.100]

3. During the past 12 months, have you had problems of the immune system?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [Source NHIS ACN.201_05.000]

4. During the past 12 months, have you been told by a doctor or other health professional that you had any kind of liver condition?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

5. During the past 12 months, have you been told by a doctor or other health professional that you had any a chronic multi-symptom illness (examples include irritable bowel syndrome, chronic fatigue syndrome, and fibromyalgia)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

6. [if B-E = yes], Did your, neurological or immune problems, chronic multi-symptom illness, or liver condition first occur before, during, or after deployment? (check all that apply.)

   1. Before deployment, 2. During deployment, 3. After deployment, 4. I do not wish to answer, Don’t know

7. On average, how many hours of sleep do you get in a 24-hour period? (Round up 30 minutes or more to the next whole hour.)

   1 Enter {1,2,3 … 24} hours

   2 I do not wish to answer

   3 Don’t know

   “Questions H and I are about snoring and breathing during sleep. To answer these questions, please consider both what others have told you and what you know about yourself.”

8. How often do you snore?

   1 Never

   2 Rarely - less than one night a week

   3 Sometimes - 1 or 2 nights a week

   4 Frequently - 3 to 5 nights a week

9. 5 Always or almost always - 6 or 7 nights a week

   6 I do not wish to answer

   7 Don’t know

10. How often do you have times when you stop breathing during your sleep?

    1 Never

    2 Rarely - less than one night a week

    3 Sometimes - 1 or 2 nights a week

    4 Frequently - 3 to 5 nights a week

    5 Always or almost always - 6 or 7 nights a week

    6 I do not wish to answer

    7 Don’t know

2.3. Height and Weight

1. How tall are you without shoes?

   1 Enter (x feet, y inches), 2 I do not wish to answer, 3 Don’t know

2. How much do you weigh without shoes?

   1 Enter X pounds, 2 I do not wish to answer, 3 Don’t know

2.4. Cancer History

[Source NHIS ACN.130_00.000]

1. Have you ever been told by a doctor or other health professional that you had Cancer or a malignancy (tumor) of any kind?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [if ‘A’ <> “Yes” skip to section 2.5]

2. What kind of cancer was it?

   01 Bladder

   2 Blood

   3 Bone

   4 Brain

   5 Breast

   6 Cervix

3. 7 Colon

   8 Esophagus

   9 Gallbladder

   10 Kidney

   11 Larynx-windpipe

   12 Leukemia

   13 Liver

   14 Lung

   15 Lymphoma

   16 Melanoma

   17 Mouth/tongue/lip

   18 Ovary

   19 Pancreas

   20 Prostate

   21 Rectum

   22 Skin (non-melanoma)

   23 Skin (Don’t Know what kind)

   24 Soft tissue (muscle or fat)

   25 Stomach

   26 Testis

   27 Throat - pharynx

   28 Thyroid

   29 Uterus

   30 Other

   31 None

   32 I do not wish to answer

   33 Don’t know

4. [if ‘B’ < 30] How old were you when this cancer was first diagnosed?

   1. Enter {00-99} Years

   2. I do not wish to answer, 3. Don’t know

5. [if ‘B’ < 30] If you were diagnosed with a second cancer, what kind of cancer was it?

   01 Bladder

   2 Blood

   3 Bone

   4 Brain

   5 Breast

   6 Cervix

   7 Colon

   8 Esophagus

   9 Gallbladder

   10 Kidney

   11 Larynx-windpipe

5. 12 Leukemia

   13 Liver

   14 Lung

   15 Lymphoma

   16 Melanoma

   17 Mouth/tongue/lip

   18 Ovary

   19 Pancreas

   20 Prostate

   21 Rectum

   22 Skin (non-melanoma)

   23 Skin (Don’t Know what kind)

   24 Soft tissue (muscle or fat)

   25 Stomach

   26 Testis

   27 Throat - pharynx

   28 Thyroid

   29 Uterus

   30 Other

   31 None

   32 I do not wish to answer

   33 Don’t know

6. [if ‘D’ < 30] How old were you when this cancer was first diagnosed?

   1. Enter {00-99} Years

   2. I do not wish to answer, 3. Don’t know

7. [if ‘D’ < 30] If you were diagnosed with a third cancer, what kind of cancer was it?

   01 Bladder

   2 Blood

   3 Bone

   4 Brain

   5 Breast

   6 Cervix

   7 Colon

   8 Esophagus

   9 Gallbladder

   10 Kidney

   11 Larynx-windpipe

   12 Leukemia

   13 Liver

   14 Lung

   15 Lymphoma

   16 Melanoma

8. 17 Mouth/tongue/lip

   18 Ovary

   19 Pancreas

   20 Prostate

   21 Rectum

   22 Skin (non-melanoma)

   23 Skin (Don’t Know what kind)

   24 Soft tissue (muscle or fat)

   25 Stomach

   26 Testis

   27 Throat - pharynx

   28 Thyroid

   29 Uterus

   30 Other

   32 I do not wish to answer

   33 Don’t know

9. [if ‘F’ < 30] How old were you when this cancer was first diagnosed?

   1. Enter {00-99} Years

   2. I do not wish to answer, 3. Don’t know

2.5. Tobacco Exposure

[Source: NHIS Adult Health Behaviors: AHB.010_00.000]

1. Have you smoked at least 100 cigarettes in your entire life?

   1. Yes

   2. No

   3. I do not wish to answer

   4. Don’t know

   [if A=Yes continue to ‘B’ else skip to ‘F’]

2. How old were you when you first started to smoke fairly regularly?

   1. Enter X (age in years),

   2. Never smoked regularly

   3. I do not wish to answer

   4. Don’t know

   [if B=age continue to ‘C’ else skip to ‘F’]

3. Do you now smoke cigarettes every day, some days or not at all?

   1. Every day

   2. Some days

   3. Not at all

   4. I do not wish to answer

   5. Don’t know

4. [if ‘C’=not at all], How long has it been since you quit smoking cigarettes?

   1. Enter {00-99} (Years since quit)

   2. I do not wish to answer

   3. Don’t know

5. [if ‘C’=some days or every day], On the average, how many cigarettes do you now smoke a day?

   1. Enter {00-99} (Number of cigarettes per day)

   2. I do not wish to answer

   3. Don’t know

6. Have you ever smoked tobacco products other than cigarettes even one time? (Such as cigars, pipes, water pipes or hookahs, small cigars that look like cigarettes, bidis, cigarillos, marijuana?)

   1. Yes

7. 2. No

   3. I do not wish to answer

   4. Don’t know

   [if F=Yes continue to ‘G’ else skip to ‘H’]

8. Do you now smoke tobacco products other than cigarettes every day, some days, rarely, or not at all?

   1. Every day

   2. Some days

   3. Rarely

   4. Not at all

   5. I do not wish to answer

   6. Don’t know

9. Have you ever used smokeless tobacco products even one time? (Such as chewing tobacco, snuff, dip, snus, or dissolvable tobacco.)

   1. Yes

   2. No

   3. I do not wish to answer

   4. Don’t know

   [if H=Yes continue to ‘I’ else skip to ‘J’]

10. Do you now use smokeless tobacco products every day, some days, rarely, or not at all?

    1. Every day

    2. Some days

    3. Rarely

    4. Not at all

    5. I do not wish to answer

    6. Don’t know

11. Are you exposed to second-hand smoke or environmental tobacco smoke every day, some days, rarely, or not at all?

    1. Every day

    2. Some days

    3. Rarely

    4. Not at all

    5. I do not wish to answer

    6. Don’t know

2.6. Deployment Smoking History

[Source: modified from DoD USAPHC DARE H2-5c]

1. [if 2.5.A = yes], Did you start smoking for the first time while being deployed?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

2. [if 2.6.A = No], How did deployment(s) change how much you smoked?

   1. No change, 2. I smoked more while deployed, 3. I smoked less while deployed,

   4. I do not wish to answer, 5. Don’t know

2.7. 12 Month Alcohol Use

1. In the PAST YEAR, how often did you ever drink any type of alcoholic beverage (Included are liquor such as whiskey or gin, beer, wine, wine coolers, and any other type of alcoholic beverage)? “On average, how many days per week did you drink?”

   1. Never, 2. Less than one, 3. 1-7 days per week, 4. I do not wish to answer, 5. Don’t know

3. Health Concerns

“Help us focus our efforts on health issues you care about.”

1. Compared to pre-deployment, would you say your overall health is better, worse, or about the same?

   1. Better, 2. Worse, 3. About the same, 4. I do not wish to answer, 5. Don’t know

2. During your deployment(s), do you believe you were sick because of something you breathed?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

3. Do you currently have a sickness or condition you think began or got worse because of something you breathed during deployment(s)?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

4. [If ‘C’=yes], When did the problem start?

   1. Before deployment

   2. During Deployment

   3. 6 months or less after deployment

   4. More than 6 months later after deployment

   5. Not sure

   6. I do not wish to answer

5. Please rate your concern that something you breathed during deployment has already affected your health.

   1. Not at all concerned, 2. a little concerned, 3. very concerned, 4. I do not wish to answer

   [If ‘E’=very or little concerned continue to F, else skip to H]

6. Please identify your biggest health concern that something you breathed during deployment has already affected your health.

   1. Lung/Respiratory/Breathing problem

   2. Heart problem

   3. Skin problem

   4. Eye problem

   5. Gastrointestinal (GI) problem

   6. Neurological problem

   7. Immune problem

   8. Effect on children or ability to have children

   9. Cancer

7. 10. Other problem

   11. I do not wish to answer

8. Have you discussed this concern with your health care provider, medical professional or team?

   1. Yes, 2. No, 3. Not yet but I would like to talk with a medical professional

9. Are you concerned that in the future that your health will be affected by something you breathed during deployment(s)

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

10. [If ‘H’=yes], Please rate your concern that something you breathed during deployment will affect your future health.

    1. Not at all concerned, 2. a little concerned, 3. very concerned, 4. I do not wish to answer

11. [If ‘I’=very or little concerned], Please identify your biggest health concern that something you breathed during deployment will affect your future health.

    1. Lung/Respiratory/Breathing

    2. Heart

    3. Skin

    4. Eyes

    5. Effect on children or ability to have children

    6. Cancer

    7. Other

    8. I do not wish to answer

12. [If ‘E’ or ‘I’=very or little concerned], Which exposure do you think has the biggest overall effect on your health?

    1. Off base air pollution during deployment (factories, cars, burning trash, dust)

    2. On base air pollution during deployment (burning fuel, burn pits)

    3. Hobbies and non-military jobs

    4. Military jobs while I’m not deployed

    5. Smoking (by you or those near you)

    6. I do not wish to answer

    7. Don’t know

4. Places You’ve Lived

“Poor air quality in places where you’ve lived may impact how deployment exposures affect you.”

[System displays current address]

1. What is your current address (complete here if not shown above [from VADIR and VA BIRLS sources], if correct skip to “5”)? Please include the city, state, zip code, and country.
   1. Country_

      [If country <> “USA” then skip to 5]

   2. City Name_
   3. State_ (two letter code)
   4. Zip code (if known):_ (5 digit number)
   5. How many years have you lived at your current address (listed above)?_ years
   6. Do you live nine or more months of the year at the address listed above? Yes, No
   7. If not, indicate the other residence.
      1. Other city name_
      2. Other state_ (two letter code)
      3. Other zip code (if known):_ (5 digit number)
      4. Other country_
2. Where have you lived the longest? Please include the city, state, zip code, and country.
   1. The address where I lived the longest is the same as my current address.

      Yes (if yes go to next question), No

   2. Country_

      [If country <> “USA” then skip to 6]

   3. City Name_
   4. State_ (two letter code)
   5. Zip code (if known):_ (5 digit number)
   6. Indicate the approximate year you moved to this address:_
   7. Indicate the approximate year you moved out of this address:_

3. Please provide the address where you lived the longest before age 13. Please include the city, state, zip code, and country.
   1. Country_

      [If country <> “USA” then skip to 5]

   2. City Name_
   3. State_ (two letter code)
   4. Zip code (if known):_ (5 digit number)
   5. Indicate the approximate age you moved to this address._ years (Enter “0” if you lived there before age 1)
   6. Indicate the approximate age you moved out of this address:_ years

5. Work History

“Exposures in your non-military jobs may impact how deployment exposures affect you.”

5.1. Current Occupational Status

1. Which of the following were you doing last week?

   1 Working for pay at a job or business

   2 With a job or business but not at work (e.g. a volunteer)

   3 Looking for work

   4 Working, but not for pay, at a family-owned job or business

   5 Not working at a job or business and not looking for work

   6 I do not wish to answer

   7 Don’t know

2. [if A=3 or 5] What is the main reason you did not [3 or 5 text: work last week/have a job or business last week]?

   1 Taking care of house or family

   2 Going to school

   3 Retired

   4 On a planned vacation from work

   5 On family or maternity leave

   6 Temporarily unable to work for health reasons

5.2. Main Occupation

1. Select the occupational category that best describes your main occupation (the civilian job you’ve held the longest). Do not include your occupation during military service. If your occupation is not included, select “other occupation”:

   1. Agricultural and fishing/hunting workers	2. Automotive, aircraft and marine mechanics and service technicians	3. Construction trade workers, helpers and other construction related workers
   4. Driver/sales workers and truck drivers	5. Extraction workers (e.g. mining or drilling)	6. Firefighters
   7. Food processing	8. Forest conservation and logging workers	9. Police and sheriff’s patrol officers
   10. Welding, soldering and brazing	11. Other occupation [text entry]	12. I do not wish to answer

2. Total years in this non-military job {0…99} years (enter 0 if less than one year).

   1. Enter {00-99} years

   2. I do not wish to answer, 3. Don’t know

5.3. Dust Exposures

1. Have you ever worked for a year or more in any dusty job outside the military?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [if A = yes, continue, else jump to 5.4]

2. For the job with the biggest dust exposure:
   1. Select the occupational category that best describes the job with the longest dust exposure. If your occupation is not included, select “other occupation”:

      1. Agricultural and fishing/hunting workers

      2. Automotive, aircraft and marine mechanics and service technicians

      3. Construction trade workers, helpers and other construction related workers

2. 4. Driver/sales workers and truck drivers	5. Extraction workers (e.g. mining or drilling)	6. Firefighters
   7. Food processing	8. Forest conservation and logging workers	9. Police and sheriff’s patrol officers
   10. Welding, soldering and brazing	11. Other occupation [text entry]	12. I do not wish to answer

3. In this job, what were the most common kinds of dust to which you were exposed (select all that apply)?

   1. Animal dander	2. Wood or sawdust	3. Metal (aluminum, copper, iron, steel, or other types)
   4. Cotton, wool, or other cloth or textile	5. Asbestos	6. Plaster
   7. Flour	8. Cement	9. Sand or silica
   10. Grain	11. Coal	12. Talc
   13. Hay	14. Fiberglass	15. Lime
   16. Paper or cardboard	17. Granite or other rock	18. Plastic or rubber
   19. Soil or dirt	20. Other dust [text entry]	21. I do not wish to answer

4. Total years in this job {0…99} years (enter 0 if less than one year).

   1. Enter {00-99} years

   2. I do not wish to answer, 3. Don’t know

5. Are you working in this dusty job now?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

5.4. Gas, Smoke, Vapors or Fumes Exposures

1. Have you ever been exposed to gas, smoke, chemical vapors or fumes in your work outside the military?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

   [if A = yes, continue, else jump to 5.5]

2. For the job with the biggest gas, smoke, vapor or fume exposure:

1. Select the occupational category that best describes the job with the longest gas, smoke, chemical vapor, or fume exposures. If your occupation is not included, select “other occupation”:

   1. Agricultural and fishing/hunting workers	2. Automotive, aircraft and marine mechanics and service technicians	3. Construction trade workers, helpers and other construction related workers
   4. Driver/sales workers and truck drivers	5. Extraction workers (e.g. mining or drilling)	6. Firefighters
   7. Food processing	8. Forest conservation and logging workers	9. Police and sheriff’s patrol officers
   10. Welding, soldering and brazing	11. Other occupation [text entry]	12. I do not wish to answer

2. In this job, what were the most common kinds of gas, smoke, or chemical vapors or fumes to which you were exposed (select all that apply)?

   1. Cutting oils or mists	2. Exhaust: primarily diesel engine	3. Exhaust: primarily gasoline engine
   4. Exhaust: both diesel and gasoline engine	5. Exhaust: primarily another kind	6. Fumes from chemicals
   7. Gasoline or other fuel fumes	8. Paint or lacquers	9. Pesticides or insecticides
   10. Smoke from burning buildings, fuel oil, refuse, or wood	11. Solvents	12. Welding
   13. Other gas, smoke, or chemical vapor or fume (indicate kind)_________	14. I do not wish to answer	15. Don’t know

3. Total years in this job {0…99} years (enter 0 if less than one year).

   1. Enter {00-99} years

   2. I do not wish to answer, 3. Don’t know

4. Are you working in this job with gas, smoke, or chemical vapors or fumes now?

   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

5.5. Asbestos Exposure

1. Have you ever worked in a job with asbestos exposure, including military service?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

      [if A = yes, continue, else jump to 5.6]

2. Circle the type(s) of asbestos exposure that describe(s) how you were exposed to.
   1. I did not handle asbestos directly, but asbestos was present on overhead pipes or ceilings, flooring, brakes, or other materials.
   2. I did not handle asbestos directly, but I worked in area where asbestos dust was created by others.
   3. I handled asbestos or asbestos containing products directly and created asbestos dust.
   4. I do not wish to answer
   5. Don’t know
3. How many years did you work in a job with asbestos exposure (enter 0 if less than one year)?
   1. Enter {00-99} years
   2. I do not wish to answer, 3. Don’t know
4. Are you working in a job with asbestos exposure now?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

6. Home Environment and Hobbies

“Exposures in your home environment or hobbies may impact how deployment exposures affect you.”

1. Are there any traditional farm animals that live on your land or that you visit on a regular basis?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know
2. Have you ever removed mold in your home because of its effect on your health?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know
3. Have you ever lived in a home that had elevated radon levels?
   1. Yes, 2. No, 3. I do not wish to answer, 4. Don’t know

4. Please select from the list below any hobbies you participate in. [Source: DoD USAPHC DARE questionnaire, page 14, section G].

   1. Woodworking, including sanding	2. Welding, brazing or soldering	3. Metal working, including machining, grinding
   4. Stained glass work	5. Hobbies utilizing epoxy resin adhesives	6. Pottery work, including glazing
   7. Indoor swimming and/or indoor ice-skating	8. None	9. I do not wish to answer,

5. [if item selected in ‘D’] How many total hours a week, on average, do you participate in all the above hobbies combined?

   1. Enter: 1,2, 3, 4, 5, 6, 7, 8, 9, 10 or more, 2. I do not wish to answer,

   3. Don’t know

7. Health Care Utilization

[Source NHIS: Adult Access to Health Care & Utilization, AAU.305_00.000]

1. About how long has it been since you last saw or talked to a doctor or other health care professional about your own health? Include doctors seen while a patient in a hospital.
   1. Never
   2. 6 months or less
   3. More than 6 months, but not more than 1 yr ago
   4. At least 1 year, but not more than 2 yrs ago
   5. At least 2 years, but not more than 5 yrs ago
   6. At least 5 years ago
   7. I do not wish to answer
   8. Don’t know
2. Do you wish to see a DoD or VA health care provider to discuss your health concerns related to airborne hazards during deployment?
   1. Yes, 2. No, 3. Don’t know

8. Contact Preferences

“Help us communicate in ways that are most effective. VA will review these responses to determine the best ways to conduct outreach.”

1. How do you prefer to receive updated information on burn pits and other airborne exposures?
   1. Email from VA
   2. VA Web site
   3. Through my health care provider
   4. VA social media (e.g. Twitter, Facebook)
   5. Letter/U.S. Mail
   6. Through the Department of Defense
   7. Through a Veterans Service Organization
   8. I do not wish to receive any updated information
2. Do you use the Internet?
   1. Yes
   2. No
   3. I do not wish to answer
   4. Don’t know
3. Do you send or receive emails?
   1. Yes
   2. No
   3. I do not wish to answer
   4. Don’t know