VetSET Screening Tool Question Title * 1. Which county in Nebraska do you live? Question Title * 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) I served in the military My husband, wife, or significant other served in the military My child served in the military My parent served in the military My brother/sister served in the military Other Other (please specify) Question Title * 3. In which branch did you or your family member serve? (mark all that apply) Army Navy Air Force Marine Corps Coast Guard Question Title * 4. Did you or your family member serve in...? (mark all that apply) Active Duty National Guard Reserve Question Title * 5. Are you currently enrolled in the VA Health Care System? Yes No Don't know Question Title * 6. In what era did you or your family member serve in the U.S. Armed Forces? September 2001 or later (OEF/OIF/OND) August 1990 to August 2001 (includes Persian Gulf War) May 1975 to July 1990 Vietnam era (August 1964 to April 1975) February 1955 to July 1964 Korean War (July 1950 to January 1955) January 1947 to June 1949 World War II (December 1941 to December 1946) November 1941 or earlier Question Title * 7. In our rural communities, what areas do you feel are the greatest needs for veterans and their families? (mark all that apply) Health Care (excluding Mental Health) Mental Health Services Substance Abuse Programs Education Transportation Employment/Job Family support Housing Assistance Marital Counseling Financial Management Other (please specify) Question Title * 8. What is your gender? Male Female Question Title * 9. Age: Question Title * 10. Would you like someone from your local health department to contact you regarding obtaining additional resources or services? Yes No Question Title * 11. Name: Question Title * 12. Address: Question Title * 13. Contact Number: Question Title * 14. E-mail address Question Title * 15. For staff only. Data entered by: Done