Student Veteran Study Intake Form

Student Veteran Study Intake Form

The purpose of the study is to predict career interest and goal persistence in student veterans. We will ask you to complete a survey which includes 3 phases, each phase should take about 20-30 minutes to complete. We will send you one phase of the survey at a time for you to complete at your own pace within one week. If you choose a paper copy, we will also send a self-addressed return envelope with postage with the survey. For each phase of the survey that you complete, you will be compensated with a $10 gift card for your time and effort for a total of up to $30. 

This electronic form is highly secured and is Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant, therefore any information you provide will be strictly confidential.

The purpose of the study is to predict career interest and goal persistence in student veterans. We will ask you to complete a survey which includes 3 phases, each phase should take about 20-30 minutes to complete. We will send you one phase of the survey at a time for you to complete at your own pace within one week. If you choose a paper copy, we will also send a self-addressed return envelope with postage with the survey. For each phase of the survey that you complete, you will be compensated with a $10 gift card for your time and effort for a total of up to $30. 

This electronic form is highly secured and is Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant, therefore any information you provide will be strictly confidential.

 

 

 

 

required6. Which is your preferred method of contact?

required6. Which is your preferred method of contact?

required7. Would you prefer the surveys to be sent to you online (via email) or on paper (via postal service)?

required7. Would you prefer the surveys to be sent to you online (via email) or on paper (via postal service)?

required8. Which year of the undergraduate program are you currently in?

required8. Which year of the undergraduate program are you currently in?

 

required9. Have you completed your basic training?

required9. Have you completed your basic training?

required10. Do you have a VA disability rating?

required10. Do you have a VA disability rating?

required11. Which gift card would you like?

required11. Which gift card would you like?

 

PTSD-5

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example: a serious accident or fire, a physical or sexual assault or abuse, an earthquake or flood, a war, seeing someone be killed or seriously injured, having a loved one die through homicide or suicide. 

required Have you ever experienced this kind of event?

required Have you ever experienced this kind of event?

required In the past month, have you had nightmares about the event(s) or thought about the event(s) when you did not want to?

required In the past month, have you had nightmares about the event(s) or thought about the event(s) when you did not want to?

required In the past month, have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

required In the past month, have you tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

required In the past month, have you been constantly on guard, watchful, or easily startled?

required In the past month, have you been constantly on guard, watchful, or easily startled?

required In the past month have you felt numb or detached from people, activities, or your surroundings?

required In the past month have you felt numb or detached from people, activities, or your surroundings?

required In the past month, have you felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

required In the past month, have you felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

required Did you have any injury(ies) during your deployment from any of the following? Check all that apply.

required Did you have any injury(ies) during your deployment from any of the following? Check all that apply.

required Did any injury you received while deployed result in any of the following? Check all that apply.

required Did any injury you received while deployed result in any of the following? Check all that apply.

required Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? Check all that apply.

required Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion? Check all that apply.

required This final question asks about distress. Distress is defined as "an unpleasant experience of an emotional, psychological, social or spiritual nature that interferes with the ability to study in college. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems due to military services that are disabling, such as true depression, anxiety, panic and feeling isolated or in a spiritual crisis.” Please choose the number between 0 and 10 that best describes how much distress you have been experiencing in the last week including today.

required This final question asks about distress. Distress is defined as "an unpleasant experience of an emotional, psychological, social or spiritual nature that interferes with the ability to study in college. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems due to military services that are disabling, such as true depression, anxiety, panic and feeling isolated or in a spiritual crisis.” Please choose the number between 0 and 10 that best describes how much distress you have been experiencing in the last week including today.

Thank you!

Thank you for completing our survey and your interest in participating in our research study! Once you hit the submit button below, we will contact you using your preferred method as soon as possible to let you know if you qualify for our study!