Visn 19 Mirecc Demographics Form Military Service Information
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1VISN 19 MIRECC Demographics Form
(Military Service Information)
MILITARY SERVICE INFORMATION
1. Branch of Military Service (Check all that apply)
Army‐ Active Duty
Naval Reserves
Army Reserves
Marine Corps‐ Active Duty
Army National Guard
Marine Corps Reserves
Air Force ‐Active Duty
Coast Guard ‐Active Duty
Air Force Reserves
Coast Guard Reserves
Air Force National Guard
National Guard‐Active Duty
Navy‐ Active Duty
National Guard Reserves
2. Years of Active Duty Service:_______
Months of Active Duty Service:_______
3. Years of Reserve Service:_______
Months of Reserve Service:_______
4. Date of separation:
Month: __________
Year: __________
5. Service Era (Check all that apply)
Pre‐Korean (Before June 1950)
Post‐Vietnam/Peacetime (May 1975‐July 1990)
Korean (June 1950‐Jan 1955)
Desert Storm/Desert Shield (Aug 1990‐Aug 2001)
Post‐Korean/Peacetime (Feb 1955‐Aug 1964)
OEF/OIF/OND (September 2001‐present)
Vietnam (Aug 1964‐May 1975)
Other
6. Highest rank at separation or current rank (Select One)
Enlisted
Non‐Commissioned Officer
Officer
7. Were you deployed?
Yes
No
8. How many times were you deployed? _____
9. Do you have a history of combat experience?
Yes
No
10. How many combat tours have you served? _____
11. While you were in the military, did you receive any uninvited and unwanted sexual attention, such as
touching, cornering, pressure for sexual favors, or inappropriate verbal remarks?
Yes
No
12. While you were in the military, did anyone ever use force or the threat of force to have sexual contact with
you against your will?
Yes
No
COMIRB #
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