Veteran Questionnaire Have you or your spouse ever served in the U.S. Military? Yes No
Are you interested in receiving one-on-one career planning or help finding employment? Yes No
If yes to both, please complete this questionnaire to be connected with an employment professional.
Section A: Current Service Members If you are currently serving on active duty, select any statements that apply to you.
I am wounded, ill, or injured AND I am receiving treatment at a military treatment facility or soldier recovery unit. I am within 1 year of separation or 2 years of retirement, AND I have participated in a part of the Transition Assistance Program (TAP). If you checked any of these, please skip to Section E: Customer Signature. Otherwise, please continue to Section B.
Section B: Eligible Veterans If you have ever served in the military, select any statements that apply to your service:
I served on active duty for more than 180 consecutive days and was discharged with other than a dishonorable discharge. (For National Guard/Reserve, active-duty training does not count toward the 180 days.) I was released from active duty because of a service-connected disability. I was released from active duty by reason of a sole survivorship discharge. I was a member of a Guard/Reserve component AND served on active duty during a period of war or in a campaign or expedition for which a campaign badge is authorized AND was discharged or released from duty with other than a dishonorable discharge. If you checked any of these, please skip to Section D. Otherwise, please continue to Section C.
Section C: Eligible Persons If you are the spouse, family caregiver, or widow(er) of someone who served or is serving in the Armed Forces, select any of the following statements that apply to you:
I am the spouse or family caregiver of a wounded, ill, or injured current service member who is receiving care at a military treatment facility. If you checked the box above, skip to Section E. Otherwise, please continue:
My spouse was a veteran who died because of a service-connected disability. My spouse has (or my deceased spouse had) a total and permanent service-connected disability rating from the U.S. Department of Veterans Affairs. My active-duty spouse is listed as one of the following and has been for more than 90 days: 1) missing in action; 2) captured in the line of duty by a hostile force; or 3) forcibly detained or interned in the line of duty by a foreign government power. If you checked any of the boxes in this part of Section C, please continue to Section D. Otherwise, please stop here. You may be eligible for priority of service from another staff member.
Notice To Our Customers: We are requesting this information to best meet your employment and training needs. We will keep all information you provide to us confidential to the greatest extent allowed by law. If you do not provide this information, you will not be subjected to any adverse treatment.
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