Form VA Form 10-21092c VA Form 10-21092c Survey of Chronic Gastrointestinal Illness in Persian Gu

Department Of Veterans Affairs
First Gulf War
Digestive Health Study

SURVEY OF
CHRONIC GASTROINTESTINAL ILLNESS
IN PERSIAN GULF VETERANS
OMB 2900-XXXX
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of this Act. The public reporting burden for this
collection of information is estimated to average 45 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. No person will be penalized for failing to furnish this information if it
does not display a currently valid OMB control number. Response to this survey is voluntary and failure to
furnish this information will have no effect on any of your applications for benefits. This information is
collected under the authority of 38 USC, Part 1, Chapter 5, Section 527 and is intended to fulfill the need
identified by the Department of Veterans in their call for measurement and evaluation of programs. Response
to this survey is voluntary and failure to furnish this information will have no effect on any of your benefits.
The Privacy Act: The execution of this form does not authorize the release of information other than that
specifically described below. The information requested on this form is solicited under Title 38, U.S.C.
Information on these forms will become part of a system of records which complies with the Privacy Act of
1974. This system is identified as "Veteran, Patient, Employee and Volunteer Research and Development
Project Records-VA (34VA12)" as set forth in the Compilation of Privacy Act Issuances via online GPO access
at
http://www.gpoaccess.gov/privacyact/index.html.

VA FORM 10-21092C
FEBRUARY 2009

Background Questions

VA FORM 10-21092C
FEBRUARY 2009

OMB 2900-XXXX
Estimated Burden: 5 minutes

General Health Questions

HOW MUCH WERE YOU DISTRESSED BY:

VA FORM 10-21092C
FEBRUARY 2009

OMB 2900-XXXX
Estimated Burden: 5 minutes

Digestive Health Questions

VA FORM 10-21092C
FEBRUARY 2009

OMB 2900-XXXX
Estimated Burden: 15 minutes

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

Current Digestive Health Questionnaire

First, we would like to ask you some questions
about any stomach, belly, or tummy pain or
discomfort in the last three months.

Skip to question 14
Continue with survey below
Stomach or belly pain can be difficult to describe
and sometimes more than one type of pain or
discomfort can occur. Please think about the
usual or primary type of pain you have. We would
like to ask you some questions only about the
USUAL or PRIMARY pain or discomfort in your
stomach or belly.

VA FORM 10-21092C
FEBRUARY 2009

OMB 2900-XXXX
Estimated Burden: 14 minutes

VA FORM 10-21092C
FEBRUARY 2009

An important purpose of this study is to learn
about bowel habits in the community in the last
3 months.

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

NEXT, WE WOULD LIKE TO ASK YOU ABOUT
OTHER COMPLAINTS.

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

VA FORM 10-21092C
FEBRUARY 2009

IMPORTANT: For each of the symptoms or illnesses below, please
indicate how often it occurred and how bothersome it was in the last year.

VA FORM 10-21092C
FEBRUARY 2009

OMB 2900-XXXX
Estimated Burden: 6 minutes

VA FORM 10-21092C
FEBRUARY 2009

Additional Questions About Digestive Health