FLORIDA AGENT ORANGE SURVEY SAMPLE

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It is very important that you answer all Yes or No responses.


Please enter the survey number from the Personal Data Form HERE :

Begin Questionair

1) Did you serve in the U.S. Armed forces? : Yes No

2) Branch of Service

3) Date of Military Service From: TO:

4) Did you serve in Vietnam, Cambodia, Laos, or the contigueos waters Surrounding any of these countries ? Yes No

5) Did you serve in IndoChina in a non-military capacity, such as Red Cross or other civilian or Government agency ?

6) If you served in Indo-China in a non-military capacity, by whom were you Employed, and what did you do

Dates of Service in S.E. Asia
7) Dates of Vietnam service (First Tour) From : To :

8) Dates of Vietnam service (Second Tour) From : To :

9) Dates of Vietnam service (Third Tour) From : To :



10) Please fill in the next boxes with the requested information... If you are not entering any info in thes boxes, PLEASE type NA to indicate Non Applicable. Please DO NOT leave any box blank.
a) Enter the outfit who you spent most of your tour with in Vietnam
b) If you were with more than one outfit, enter who you were also with, ( list just the outfit which you spent the next greatest amount of time with ) :
c) If you had a second tour, enter the outfit who you spent most of your second tour with in Vietnam
d) If you were in more than one outfit on your second tour, enter the outfit you were also with ( list just the outfit which you spent the next greatest amount of time with ) :
e) If you had a third tour, enter the outfit who you spent most of your third tour with in Vietnam
f) If you were in more than one outfit on your third tour, enter the outfit you were also with ( list just the outfit which you spent the next greatest amount of time with ) :

11) Enter your Primary MOS while on your first Tour (please type in a number or NA) :
a) Now your Secondary MOS if Aplicable (please type in a number or NA) :
b) If you served more than one tour, enter your Primary MOS while on your second Tour (please type in a number or NA) :
c) Now your Secondary MOS if Aplicable (please type in a numberor NA) :
d) Please do the same as above if you served a third tour. ( Enter your Primary MOS while on your third Tour, please type in a number) :
e) Now your Secondary MOS if Aplicable (please type in a number or NA) :

12) In which Major Corp area did you operate, and when were you there ? :

Use map if needed Click here for map of Vietnam

If you were in these area's check the appropriate box
I Corp : When were You there, From : To :
II Corp : When were You there, From : To :
III Corp : When were You there, From : To :
IV Corp : When were You there, From : To :

13) At which Airport, Port, or Location did you Enter Vietnam ? :
(First Tour) : (Second Tour) : (Third Tour) :

14) At which Airport, Port, or Location did you Leave Vietnam ? :
(First Tour) : (Second Tour) : (Third Tour) :

15) What was your Rank, Rate, or Grade when you Entered Vietnam :

16) What was your Rank, Rate, or Grade when you Left Vietnam :

17) Did you spend time in the Field ? : Yes No

18) How Much Total time did You spend in the Field ?... (Months)

19) Did you ever drink water which came directly from the field, jungle, rice paddies, or wells ? Yes No

20) Did you bathe in streams, rivers, lakes, creeks, or any other body of water in Vietnam ? Yes No

21) Did you operate in an area or area's in which you actually saw Agent Orange being sprayed, dropped or used ?
Yes No

22) Did you operate in an area or area's in which you observed the effects of jungle or undergrowth defoliation ?
Yes No

23) Did you engage in field operations which required the crossing of streams, creeks, rivers, lakes, or other water areas ? Yes No

24) Did you eat food which was cooked in the field ? Yes No

25) Did you sleep in the Field ? Yes No

26) While in Vietnam, did you engage in any perimeter clearing operations ? Yes No

27) Were you wounded in Vietnam ? Yes No

28) If Yes, how many times were you wounded ?

29) Which area(s) of your body was wounded ? Click "Yes" to all that apply :
Head / Face Eyes Ears Throat / Neck Chest
Abdomen/Stomach Back Spine
Genitals Left arm / Hand or Fingers Right Arm / Hand and or Fingers
Left leg / Foot and or Toes Right leg / Foot and or Toes


30) If you were wounded in Vietnam, please select type :
a)
If wounded more than once select again here, if not leave NA : b)
If wounded more than Twice select here, if not leave NA: c)

31) While in Vietnam, were you treated for any minor medical condition (exclude any mental or Dental treatment) such as illness or minor wounds which did NOT require hospitalization ? Yes No

32) While you were in Vietnam, were you treated for any mental emotional, or psychological condition ? Yes No

33) While in Vietnam, were you treated for any Dental problems (including any extractions or other treatment) ? Yes No

34) Were you hospitalized in Vietnam ? Yes No
If yes, when, (chose) If not leave NA : Where ? : Why ? :

35) Did you recieve Blood tranfusion(s) in Vietnam ? Yes No

36) While in Vietnam, did you sustain any injury, illness or disease which required medical, dental or psychological treatment NOT associated with hostile action?Yes No

37) At the time of your arrival in Vietnam, your general health was :

38) At the time you finally left Vietnam, Your general health was :

This is the end of the sample.


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