VA and DOD Health Care: Administration of DOD's Post-Deployment  
Health Reassessment to National Guard and Reserve Servicemembers 
and VA's Interaction with DOD (25-JAN-08, GAO-08-181R). 	 
                                                                 
Congress's long-standing interest in health care services for	 
servicemembers returning from deployment has grown regarding	 
National Guard and Reserve servicemembers because they are being 
activated in numbers not seen since World War II. For		 
servicemembers who have been deployed overseas--whether National 
Guard, Reserve, or active duty--the Department of Defense (DOD)  
has developed a continuum of programs to assess servicemembers'  
health needs by obtaining information on their health concerns.  
One health assessment is administered before deployment, another 
about the time servicemembers return from deployment, and a third
90 to 180 days after deployment, which is called the		 
post-deployment health reassessment (PDHRA). DOD directed the	 
PDHRA to be implemented in June 2005 in response to studies that 
showed that health concerns were emerging several months after	 
servicemembers' return from deployment. One intent of the PDHRA  
is to identify servicemembers' health concerns with a specific	 
emphasis on screening for mental health and to assess whether	 
servicemembers need referrals for further evaluation. PDHRAs can 
result in referrals being made to military treatment facilities, 
TRICARE providers, chaplains, Military OneSource, or Department  
of Veterans Affairs (VA) facilities, such as VA medical centers, 
VA community clinics, and Vet Centers. Congressional interest in 
health care services for National Guard and Reserve		 
servicemembers returning from deployment has increased because of
their large numbers and because they have reported		 
post-deployment mental health concerns at a higher rate than	 
their active duty counterparts, though this varies by military	 
service. Related to this interest, Congress asked us to describe 
the administration of the PDHRA to National Guard and Reserve	 
servicemembers. This report describes: (1) how DOD administers	 
the PDHRA to National Guard and Reserve servicemembers and what  
information it obtains and (2) how VA interacts with DOD in the  
PDHRA process for these servicemembers and the information VA	 
obtains.							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-181R					        
    ACCNO:   A80150						        
  TITLE:     VA and DOD Health Care: Administration of DOD's	      
Post-Deployment Health Reassessment to National Guard and Reserve
Servicemembers and VA's Interaction with DOD			 
     DATE:   01/25/2008 
  SUBJECT:   Health care planning				 
	     Health care programs				 
	     Health care reform 				 
	     Health care services				 
	     Mental health					 
	     Military health services				 
	     Military personnel 				 
	     Military personnel deployment			 
	     Military policies					 
	     Military reserve personnel 			 
	     Strategic planning 				 

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GAO-08-181R

   

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January 25, 2008

Congressional Requesters

Subject: VA and DOD Health Care: Administration of DOD's Post-Deployment
Health Reassessment to National Guard and Reserve Servicemembers and VA's
Interaction with DOD

Congress's long-standing interest in health care services for
servicemembers returning from deployment has grown regarding National
Guard and Reserve servicemembers because they are being activated in
numbers not seen since World War II.1, 2 For servicemembers who have been
deployed overseas--whether National Guard, Reserve, or active duty--the
Department of Defense (DOD) has developed a continuum of programs to
assess servicemembers' health needs by obtaining information on their
health concerns. One health assessment is administered before deployment,
another about the time servicemembers return from deployment, and a third
90 to 180 days after deployment, which is called the post-deployment
health reassessment (PDHRA). DOD directed the PDHRA to be implemented in
June 2005 in response to studies that showed that health concerns were
emerging several months after servicemembers' return from deployment.3 One
intent of the PDHRA is to identify servicemembers' health concerns with a
specific emphasis on screening for mental health and to assess whether
servicemembers need referrals for further evaluation. PDHRAs can result in
referrals being made to military treatment facilities, TRICARE providers,4
chaplains,
Military OneSource,5 or Department of Veterans Affairs (VA) facilities,
such as VA medical centers, VA community clinics, and Vet Centers.6

1See Related GAO Products at the end of this report.

2Between September 2001 and October 2007, nearly 620,000 National Guard
and Reserve servicemembers have been activated in support of the Global
War on Terrorism.

3For purposes of this report, we define servicemembers to include members
of the National Guard and Reserves who fall under DOD's continuum of care
because of their active duty service overseas, even if they are no longer
on active duty at the time the PDHRA is administered.

4DOD provides health care through TRICARE--a regionally structured program
that uses civilian contractors to maintain provider networks to complement
health care services provided at military hospitals and clinics, commonly
referred to as military treatment facilities. While servicemembers are on
active duty, DOD manages where they receive their care--at a military
treatment facility, a TRICARE civilian provider, or a VA medical facility.

Congressional interest in health care services for National Guard and
Reserve servicemembers returning from deployment has increased because of
their large numbers and because they have reported post-deployment mental
health concerns at a higher rate than their active duty counterparts,
though this varies by military service.7 Related to this interest, you
asked us to describe the administration of the PDHRA to National Guard and
Reserve servicemembers.8 This report describes (1) how DOD administers the
PDHRA to National Guard and Reserve servicemembers and what information it
obtains and (2) how VA interacts with DOD in the PDHRA process for these
servicemembers and the information VA obtains.

Our work focused on National Guard (federally activated) and Reserve
servicemembers from the military services who have been deployed overseas
greater than 30 days to locations without a permanent military treatment
facility.9 National Guard servicemembers included the Army National Guard
and the Air National Guard. Reserve servicemembers included Army Reserve,
Navy Reserve, Air Force Reserve, and Marine Corps Reserve. We did not
include Coast Guard Reserve servicemembers since they represent less than
1 percent of the population of activated Reserve and National Guard
servicemembers.

To describe how DOD administers the PDHRA to National Guard and Reserve
servicemembers and what information it obtains, we interviewed and
obtained documents from relevant DOD officials from the Force Health
Protection and Readiness Program in the Office of the Assistant Secretary
of Defense (Health Affairs), the Army Medical Surveillance Activity, and
each of the military services identified above. In addition, we
interviewed and obtained documents from the health care contractor DOD
uses to administer the PDHRA to National Guard and Reserve servicemembers.
Further, we obtained completion and referral data from PDHRA
administrations conducted from June 2005 through January 1, 2008. We
assessed the reliability of those data by reviewing system documentation,
interviewing knowledgeable agency officials, and testing the data to
search for incorrect or missing values. We determined the data were
sufficiently reliable for the purposes of this report. To describe how VA
interacts with DOD in the PDHRA process for these servicemembers, we
interviewed, and collected supporting documentation from VA officials from
the Office of Seamless Transition, Office of Readjustment Counseling,
Office of Mental Health, and Veterans Integrated Service Networks (VISN)
offices.10 We also interviewed and obtained documents from DOD's
contractor officials and relevant DOD officials from the Force Health
Protection and Readiness Program in the Office of the Assistant Secretary
of Defense (Health Affairs), the Army Medical Surveillance Activity, and
each of the military services identified above.

5For National Guard, Reserve, and active duty servicemembers and their
families, Military OneSource provides educational products on the Web and
counseling on a variety of topics by phone and face to face.

6VA's integrated health care system provides primary care, specialized
care, and related medical and social support services. VA medical centers
provide a broad range of inpatient and outpatient medical services,
including mental health services, to servicemembers and veterans meeting
eligibility criteria. VA community clinics provide medical services, which
may include mental health services, on an outpatient basis in local
communities. Vet Centers provide mental health services, including
readjustment counseling, to all veterans who served in any combat zone.

7Colonel Charles W. Hoge, M.D., Director of Division of Psychiatry and
Neuroscience, Walter Reed Army Institute of Research provided this
comparative information in September 28, 2006, testimony before the
Committee on Veterans' Affairs, Subcommittee on Health, House of
Representatives.

8You asked us to describe the administration of the PDHRA either in
requests focused on this subject or in requests for this information as
part of a larger body of work. As requested, we are also conducting work
on related issues for which we plan to issue additional reports.

9For purposes of this report, we consider the National Guard to be
federally activated when it is performing a federal mission conducted
under the command and control of the President and mobilized under
authority contained in Title 10, U.S. Code. These mobilization authorities
include, for example, 10 U.S.C. S 12302 and S 12304.

In addition, to address both objectives, we observed in-person
administrations of PDHRAs to Army National Guard servicemembers in
Kinston, North Carolina, during a weekend meeting (called a drill weekend)
and to Army Reserve servicemembers in Indianapolis, Indiana, during a
drill weekend. We chose these sites because they are located in different
regions of the country and located in areas with respectively smaller and
larger populations. We visited Army National Guard and Reserve units
because they comprised about 80 percent of deployed National Guard
(federally activated) and Reserve servicemembers at the time of our review
(July 2007). While this sample of site visits allowed us to learn about
many important aspects of PDHRA administrations, the information does not
permit us to generalize about PDHRA administrations departmentwide. At
these sites, we met with and collected supporting documentation from
officials responsible for administering the PDHRA and officials from VA
medical centers, a VA community clinic, and Vet Centers. We conducted our
work from April 2007 through January 2008 in accordance with generally
accepted government auditing standards.

Results in Brief

DOD uses a health care contractor in all but a small number of cases to
administer the PDHRA to National Guard and Reserve servicemembers either
in person or by telephone through a call center. Specifically, DOD
contracts with a company that provides administrative staff and health
care providers--physicians, physician's assistants, and nurse
practitioners--to administer the assessments. The PDHRA form asks for
demographic information--such as the servicemember's date of birth,
gender, and marital status--and health information that can lead to
referrals for additional evaluation. For example, the PDHRA asks
servicemembers questions about the occurrence of nightmares, conflicts
with family and friends, and increased alcohol use. Servicemembers who
answer affirmatively to these questions may receive a referral for further
evaluation for mental health conditions, such as post-traumatic stress
disorder or alcohol abuse. These referrals result from in-person or
telephone discussions that take place between the servicemember and the
health care provider during the PDHRA administration. Of the about 156,000
PDHRAs completed by National Guard and Reserve servicemembers from June
2005 through January 1, 2008, nearly 46 percent resulted in referrals for
further evaluation for physical or mental health concerns.

10The VA health care system is organized into 21 geographically defined
regions, or VISNs, that have budget and management responsibilities for VA
facilities in their geographic area.

According to our discussions with VA and DOD officials, VA officials
interact with DOD officials in the PDHRA process in several ways and
receive information about servicemembers from DOD. Through coordination
with DOD, VA officials are generally present when PDHRAs are administered
to National Guard and Reserve servicemembers during drill weekends,
whether the PDHRAs are administered in person or by telephone through a
call center. VA interaction with DOD also occurs when servicemembers are
referred to a VA facility. VA staff provide servicemembers with
information about VA benefits and help them make appointments at VA
facilities.11 Information VA receives from DOD includes the location of
PDHRA administrations, numbers of servicemembers referred to VA
facilities, and the PDHRAs of individual servicemembers who access VA
health care. Of the National Guard and Reserve servicemembers referred
through the PDHRA process for either physical or mental health concerns
from June 2005 through January 1, 2008, 47 percent (almost 34,000) were
referred to VA facilities.

VA and DOD concurred with a draft of this report.

Background

Almost all National Guard and Reserve servicemembers serve in the military
on a part-time basis while maintaining a civilian career. When not
deployed, they usually meet 1 weekend a month for a drill weekend and 2
weeks a year for annual training. Commanding officers are responsible for
ensuring that servicemembers in their military units are medically ready
to be deployed. As part of that effort, they are responsible for having
servicemembers in their unit complete deployment health assessments.

DOD's deployment-related continuum of health care includes three health
assessments, which are used to determine whether further evaluation is
needed for servicemembers deployed overseas greater than 30 days to
locations without a permanent military treatment facility.12 They do not
diagnose medical conditions. The pre-deployment health assessment is
documented on Department of Defense Form 2795 and is administered within
60 days before deployment. It is a mandatory health assessment for most
servicemembers deploying overseas. The post-deployment health assessment
is documented on Department of Defense Form 2796 and must be completed
between 30 days prior to leaving a deployment location and within 30 days
after returning from deployment. It is a mandatory health assessment for
servicemembers returning from deployment. The PDHRA is documented on
Department of Defense Form 2900 (DD 2900) and is administered 90 to 180
days after returning from deployment.13 (See encl. I.) While it is
mandatory that DOD offer servicemembers the opportunity to participate in
the PDHRA, servicemembers are only required to answer limited demographic
questions; they are not required to answer any of the health questions.
Further, those who have left the military have the option to complete the
PDHRA but are not required to do so.

11VA provides a range of benefits to eligible veterans, including
disability compensation and pensions, education benefits, and hospital and
medical care.

12It is the commander's decision whether servicemembers who do not meet
the criteria complete these health assessments.

13Although a new DD 2900 dated September 2007 has been developed, it had
not been implemented as of January 7, 2008. This report refers to the DD
2900 dated June 2005.

While the pre- and post-deployment health assessments were established in
response to legislation, the PDHRA was created independently by DOD.14 In
2004, researchers published articles that indicated servicemembers
reported a significant increase in mental health concerns 90 to 120 days
after returning from deployment compared with mental health concerns
reported before or just after deployment.15 In response, DOD developed the
PDHRA process to provide identification of health concerns during this
post-deployment time frame and to assess whether servicemembers need
referrals for further evaluation. DOD and international health experts
worked jointly with VA mental health experts to develop the DD 2900.

Veterans who have served in combat in certain conflicts, including those
from the National Guard and Reserves, are presumed to be eligible for VA
health care services for any condition for 2 years from the date of
separation from military service, even if there is insufficient medical
evidence to conclude that the condition is attributable to military
service.16 This 2-year presumptive eligibility includes those National
Guard and Reserve members who have left active duty and returned to their
units. If veterans do not enroll until after the 2-year presumptive
period, they will be subject to the same eligibility and enrollment rules
as other veterans, who generally have to prove that a medical problem is
connected to their military service or that they have incomes below
certain thresholds.17

PDHRA, Administered in Person or through a Call Center, Provides DOD with
Servicemembers' Health Information

DOD generally administers the PDHRA to National Guard and Reserve
servicemembers using a health care contractor either in person or by
telephone through a call center, depending on the number of individuals
being assessed.18 DOD officials said their contract officials generally
administer the PDHRA in person when they can achieve economies of scale,
that is, when a sufficient number of servicemembers--at least 60--are
scheduled for an assessment at a drill location. At in-person
administrations, contractor personnel--including administrative staff and
health care providers--go to the drill location. Contractor officials
stated that most PDHRAs are administered to Army National Guard
servicemembers in person because they generally deploy in large enough
groups.

14The pre- and post-deployment health assessments were established in
response to a provision in the National Defense Authorization Act for
Fiscal Year 1998. See Pub. L. No. 105-85, S 765(a)(1), 111 Stat. 1629,
1826-27 (codified as amended as 10 U.S.C. S 1074f). The Assistant
Secretary of Defense for Health Affairs directed all military services to
conduct health reassessments of servicemembers at 90 to 180 days
post-deployment. He directed implementation plans to begin 90 days after
March 10, 2005.

15P. D. Bliese, K. M. Wright, A. B. Adler, et al., Screening for Traumatic
Stress Among Re-Deploying Soldiers, U.S. Army Medical Research Unit-Europe
Research Report 2004-001 (Heidelberg, Germany: USAMRU-E, 2004) and C. W.
Hoge, C. A. Castro, S. C. Messer, et al., Combat Duty in Iraq and
Afghanistan, Mental Health Problems, and Barriers to Care (Boston, MA: The
New England Journal of Medicine, 351, 2004).

16To be eligible, the veteran must have served in combat during a period
of war after the Persian Gulf War or against a hostile force during a
period of hostilities after November 11, 1998. See 38 U.S.C. S
1710(e)(1)(D); VHA Directive 2005-020, Determining Combat Veteran
Eligibility (June 2, 2005). "Hostilities" is defined as an armed conflict
in which servicemembers are subjected to danger comparable to the danger
encountered in combat with enemy armed forces during a period of war, as
determined by the Secretary of VA. See 38 U.S.C. S 1712A(a)(2)(B).
Eligibility under 38 U.S.C. S 1710(e)(1)(D) does not extend, however, to
veterans whose disabilities are found to have resulted from a cause other
than the service described in the statute. H.R. 1585, the National Defense
Authorization Act for Fiscal Year 2008, contains a provision that would
extend the length of the presumptive eligibility for certain combat
veterans. The House and Senate approved this bill in December, 2007.
However, on December 27, 2007, the President issued a memorandum
indicating his disapproval of H.R. 1585 and declined to sign the
legislation.

17See 38 U.S.C. SS 1705, 1710; 38 C.F.R. S 17.36 (2007).

According to DOD officials, when fewer than 60 servicemembers are being
assessed, PDHRAs are administered by telephone through a call center
operated by DOD's health care contractor. Contractor officials indicated
that the Air National Guard and the Army, Navy, and Marine Corps Reserves
typically use the call center because they tend to deploy servicemembers
in small groups. DOD officials told us that for administrations using the
call center, commanding officers decide whether servicemembers complete
PDHRAs by phone during a drill weekend or during their personal time.

Whether administered in person or through the call center, the DD 2900
consists of two sets of questions--one set answered by servicemembers and
the other by health care providers. Servicemembers answer the first set of
questions online. These questions ask about servicemembers'
demographics--such as the servicemember's date of birth, gender, and
marital status--and health concerns. The second set of questions is
completed by a health care provider--typically a physician, physician's
assistant, or nurse practitioner. The provider discusses with the
servicemember answers from the first set of questions and uses that
information to answer the second set of questions, which ask the provider
to assess servicemember's health concerns and make referrals if needed.19

DOD obtains information from the PDHRA process that can lead to referrals
for additional evaluations. For example, the PDHRA includes questions
about the occurrence of nightmares, conflicts with family and friends, and
increased alcohol use. Servicemembers who answer affirmatively to these
questions may need further evaluation for mental health conditions, such
as post-traumatic stress disorder or alcohol abuse. Of the about 156,000
DD 2900s completed by National Guard and Reserve servicemembers between
June 2005 and January 1, 2008, about 46 percent resulted in referrals for
further evaluation for physical or mental health concerns.

VA Interacts with DOD in the PDHRA Process and Receives PDHRA Information
from DOD

According to our discussions with VA and DOD officials, VA officials
interact with DOD in the PDHRA process in several ways. VA staff routinely
attend when PDHRAs are to be administered in person. DOD's health care
contractor provides VA's senior military liaison with information about
the location and schedule as well as the number of National Guard and
Reserve servicemembers expected to be assessed. Local VA officials told us
that when they are scheduled to attend a PDHRA in-person administration,
they contact the unit's commanding officer or the officer's representative
to obtain information on the unit's combat experiences and to coordinate
the number of VA staff and materials needed for the number of
servicemembers scheduled to complete PDHRAs. At our site visits, we
observed officials from VA medical centers and Vet Centers providing
servicemembers with information about VA benefits, enrolling
servicemembers in the VA, and helping servicemembers make appointments at
VA facilities. At our Indianapolis site visit, local VA officials provided
Army Reserve servicemembers with appointment contact information for VA
facilities located not only in Indiana but also in Arizona, California,
Georgia, Illinois, Kentucky, Michigan, Ohio, and Texas for servicemembers
who lived outside of Indiana.20 VA officials we interviewed at
headquarters, the VISN, and the local office noted that PDHRA
administrations provide one of the best ways for VA to give information
about their benefits to National Guard and Reserve servicemembers.

18The Air National Guard requires the PDHRA to be administered in person
by a military provider to servicemembers assigned to the Personnel
Reliability Program. In addition, since the Air Force Reserves are small
in number and co-located on an Air Force Base with active duty
servicemembers, their PDHRAs are usually administered in person by a
military provider.

19The Army National Guard and Army, Navy, and Marine Corps Reserves all
require servicemembers to speak with a health care provider. However, most
of the Air National Guard and all Air Force Reserve servicemembers are not
required to speak with a provider if they report no health concerns on the
DD 2900.

VA officials told us they also interact with DOD when the PDHRA is
administered through the call center. When units schedule PDHRA
administrations using the call center during drill weekends, VA officials
told us they generally coordinate in the same ways as they do for
in-person PDHRA administrations. For example, a headquarters official said
local VA officials usually go to the unit's location to provide
educational materials about VA benefits, enroll servicemembers in VA, and
help them make appointments at VA facilities. Officials at VA headquarters
and a VISN indicated that VA officials also provide educational materials
for servicemembers who complete PDHRAs using the call center when the
assessments are not administered on a drill weekend. For example, for a
unit in Jacksonville, Florida, a VISN official sent the unit's commanding
officer packets of information for distribution to the servicemembers at
the unit's next drill weekend. The information included VA enrollment
forms and brochures about VA benefits. Regardless of whether the PDHRA is
administered during a drill weekend, VA and DOD interact when
servicemembers are referred to VA facilities. According to VA headquarters
and DOD officials, the contractor's call center personnel will either
connect servicemembers directly to a VA facility or give them information
to contact the facility themselves. Following the telephone interview,
call center personnel mail servicemembers a brochure about VA benefits for
National Guard and Reserve servicemembers, a copy of their DD 2900, and
contact information for the VA senior military liaison to assist them if
they experience problems getting an appointment at a VA facility.

Through interaction with DOD officials, VA officials obtain PDHRA
information about servicemembers referred to VA and individual
servicemembers' DD 2900s when they access VA health care. Each month, VA
receives a report that provides monthly and cumulative totals of
servicemembers referred, including servicemembers referred to VA
facilities. For example, the January 1, 2008, report showed that of the
number of servicemembers referred from June 2005 through January 1, 2008,
nearly 34,000 (47 percent) were referred to VA facilities for either
physical or mental health concerns. For mental health concerns, more than
11,000 servicemembers were referred to VA medical centers or clinics and
over 16,000
were referred to Vet Centers.21 VA also receives a weekly report that
lists the location of all in-person PDHRA administrations during the past
week and shows the number of referrals to VA from each PDHRA
administration. Further, when servicemembers obtain health care from VA,
VA officials have access to individual servicemembers' DD 2900s. DOD
provides VA with electronic access to servicemembers' DD 2900s, according
to headquarters VA and DOD officials. In addition, servicemembers may
provide VA officials with paper copies of their DD 2900s.

20Because of personnel shortages in Reserve units that are deploying, it
has been necessary to transfer servicemembers from units that are not
deployed into the deploying unit. The deploying units may or may not be
located in the same state as the nondeploying units.

21Servicemembers may be referred to both a VA medical center and a Vet
Center so these numbers cannot be combined to determine the total number
of individual servicemembers referred.

Agency Comments

VA and DOD reviewed a draft of this report. VA stated in an e-mail
response that it agreed with the facts presented in the report as they
pertain to VA, and had no additional comments. DOD stated that it
concurred with the report's findings and conclusions. DOD asked that we
clarify in the first paragraph that the focus of the report is National
Guard and Reserve servicemembers, and we made revisions to do so. DOD also
provided technical comments which we incorporated where appropriate. DOD's
comments are reprinted in enclosure II.

                                   - - - - -

We are sending copies of this report to the Secretary of Veterans Affairs
and the Secretary of Defense and appropriate congressional committees. We
will also make copies available to others upon request. In addition, the
report is available at no charge on the GAO Web site at
http://www.gao.gov.

If you or your staff have questions about this report, please contact me
at (202) 512-7114 or [email protected]. Contact points for our Office of
Congressional Relations and Public Affairs may be found on the last page
of this report. GAO staff members who made key contributions to this
report are listed in enclosure III.

Marjorie Kanof
Managing Director, Health Care

Enclosures - 3

List of Requesters


The Honorable Michael H. Michaud: 
Chairman Subcommittee on Health: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable Daniel K. Akaka: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Wayne Allard: 
United States Senate: 

The Honorable Christopher S. Bond: 
United States Senate: 

The Honorable Barbara Boxer: 
United States Senate: 

The Honorable Tom Harkin: 
United States Senate: 

The Honorable Joseph I. Lieberman: 
United States Senate: 

The Honorable Claire McCaskill: 
United States Senate: 

The Honorable Patty Murray: 
United States Senate: 

The Honorable Barack Obama: 
United States Senate: 

The Honorable Ken Salazar: 
United States Senate: 

The Honorable Bernard Sanders: 
United States Senate: 

The Honorable Peter Welch: 
House of Representatives: 

[End of section] 


The Honorable Michael H. Michaud: 
Chairman Subcommittee on Health: 
Committee on Veterans' Affairs: 
House of Representatives: 

The Honorable Daniel K. Akaka: 
Chairman: 
Committee on Veterans' Affairs: 
United States Senate: 

The Honorable Wayne Allard: 
United States Senate: 

The Honorable Christopher S. Bond: 
United States Senate: 

The Honorable Barbara Boxer: 
United States Senate: 

The Honorable Tom Harkin: 
United States Senate: 

The Honorable Joseph I. Lieberman: 
United States Senate: 

The Honorable Claire McCaskill: 
United States Senate: 

The Honorable Patty Murray: 
United States Senate: 

The Honorable Barack Obama: 
United States Senate: 

The Honorable Ken Salazar: 
United States Senate: 

The Honorable Bernard Sanders: 
United States Senate: 

The Honorable Peter Welch: 
House of Representatives: 

[End of section] 

Enclosure 1: Department of Defense Form 2900: 

Post-Deployment Health Reassessment (PDHRA): 

Authority: 10 U.S.C. 136 Chapter 55. 1074f, 3013, 5013, 8013 and E.O. 
9397: 

Principal Purpose: To assess your state of health after deployment in 
support of military operations and to assist military healthcare 
providers, including behavioral health providers, in identifying 
present and future medical care needs you may have. The information you 
provide may result in a referral for additional healthcare that may 
include behavioral healthcare. 

Routine Use: To other Federal and State agencies and civilian 
healthcare providers as necessary in order to provide necessary medical 
care and treatment. Responses may be used to guide possible referrals. 

Disclosure: Disclosure is voluntary. 

Instructions: Please read each question completely and carefully before 
making your selections. Provide a response for each question. If you do 
not understand a question, ask the administrator. Please respond based 
on your Most Recent Deployment. 

Demographics: 

Last Name: 
First Name: 
MI: 
DOB (dd/mm/yyyy): 
Today's Date (dd/mm/yyyy): 
Date arrived theater (mm/yyyy):	
Date departed theater (mm/yyyy): 
Social Security Number: 
		
Gender:	
Male: 
Female: 

Service Branch:	
Air Force: 
Army: 
Navy: 
Marine Corps: 
Coast Guard: 
Other: 

Status Prior to Deployment: 
Active Duty: 
Selected Reserves- Reserve - Unit: 
Selected Reserves- Reserve - AGR: 
Selected Reserves- Reserve - IMA: 
Selected Reserves- National Guard - Unit: 
Selected Reserves- National Guard - AGR: 
Ready Reserves - IRR: 
Ready Reserves - ING: 
Civilian Government Employee: 
Other: 

Pay Grade: 
E1: 
E2: 
E3: 
E4: 
E5: 
E6: 
E7: 
E8: 
E9: 
001: 
002: 
003: 
004: 
005: 
006: 
007: 
008: 
009: 
010: 
W1: 
W2: 
W3: 
W4: 
W5: 
Other: 

Marital Status:						
Never Married: 			
Married: 
Separated: 
Divorced: 
Widowed: 

Location of Operation:	
Iraq: 
Afghanistan: 
Kuwait: 
Qatar: 
Bosnia/Kosovo: 
SW Asia - other: 
Africa: 
South America: 	
North America: 
Australia: 
Europe: 
On a ship: 
Other: 

Since return from deployment I have:	
Maintained/returned to previous status: 
Transitioned to Selected Reserves: 
Transitioned to Ready Reserves: 
Retired from Military Service: 
Separated from Military Service: 

Current Contact	Information: 	
Phone: 
Cell: 		
DSN: 		
Email: 
Address: 

Total Deployments in Past 5 Years:	
OIF: 
1: 
2: 
3: 
4: 
5 or more: 

OEF: 
1: 
2: 
3: 
4: 
5 or more: 

Other: 
1: 
2: 
3: 
4: 
5 or more: 

Current Unit of Assignment: 

Current Assignment Location: 

Point of Contact who can always	reach you: 
Name: 
Phone: 
Email: 
Mailing Address: 

1. Overall, how would you rate your health during the Past Month?
Excellent: 
Very Good: 
Good: 
Fair: 
Poor: 

2. Compared to before your most recent deployment, how would you rate 
your health in general now?
Much better now than before I deployed: 
Somewhat better now than before I deployed: 
About the same as before I deployed: 
Somewhat worse now than before I deployed: 
Much worse now than before I deployed: 

3. Since you returned from deployment, about how many times have you 
seen a healthcare provider for any reason, such as in sick call, 
emergency room, primary care, family doctor, or mental health provider? 
No visits: 
1 visit: 
2-3 visits: 
4-5 visits: 
Over 6 visits: 

4. Since you returned from deployment, have you been hospitalized? 
Yes: 
No: 

5. During your deployment, were you wounded, injured, assaulted or 
otherwise physically hurt? 
Yes: 
No: 
If NO, skip to Question 6. 

5a. IF YES, are you still having problems related to this wound, 
assault, or injury? 
Yes: 
No: 
Unsure: 

6. Other than wounds or injuries, do you currently have a health 
concern or condition that you feel is related to your deployment? IF 
NO, skip to Question 7. 

6a. IF YES, please mark the item(s) that best describe your deployment-
related condition or concern: 
Chronic cough: 
Redness of eyes with tearing: 
Runny nose: 
Dimming of vision, like the lights were going out: 
Fever: 
Chest pain or pressure: 
Weakness: 
Dizziness, fainting, light headedness: 
Headaches: 
Difficulty breathing: 		
Swollen, stiff or painful joints: 
Diarrhea, vomiting, or frequent indigestion: 
Back pain: 
Problems sleeping or still feeling tired after sleeping: 
Muscle aches: 
Difficulty remembering: 
Numbness or tingling in hands or feet: 
Increased irritability: 
Skin diseases or rashes: 
Taking more risks such as driving faster: 
Ringing of the ears: 
Other:: 

7. Do you have any persistent major concerns regarding the health 
effects of something you believe you may have been exposed to or 
encountered while deployed? IF NO, skip to Question 8. 

7a. IF YES, please mark the item(s) that best describe your concern:
DEET insect repellent applied to skin: 
Paints: 
Pesticide-treated uniforms: 
Radiation: 
Environmental pesticides (like area fogging): 
Radar/microwaves: 
Flea or tick collars: 
Lasers: 
Pesticide strips: 
Loud noises: 
Smoke from oil fire: 
Excessive vibration: 
Smoke from burning trash or feces: 
Industrial pollution: 
Vehicle or truck exhaust fumes: 
Sand/dust: 
Tent heater smoke: 
Blast or motor vehicle accident: 
JP8 or other fuels: 
Depleted Uranium (if yes, explain): 
Fog oils (smoke screen): 		
Solvents: 
Other: 

8. Since return from your deployment, have you had serious conflicts 
with your spouse, family members, close friends, or at work that 
continue to cause you worry or concern? 
Yes: 
No: 
Unsure: 

9. Have you had any experience that was so frightening, horrible, or 
upsetting that, In The Past Month, you: 
a. Have had any nightmares about it or thought about it when you did 
not want to: 
Yes: 
No: 

b. Tried hard not to think about it or went out of your way to avoid 
situations that remind you of it: 
Yes: 
No: 

c. Were constantly on guard, watchful, or easily startled: 
Yes: 
No: 

d. Felt numb or detached from others, activities, or your surroundings: 
Yes: 
No: 

10. a. In the Past Month, did you use alcohol more than you meant to? 
Yes: 
No: 

b. In the Past Month, have you felt that you wanted to or needed to cut 
down on your drinking? 
Yes: 
No: 

11. Over the Past Month, have you been bothered by the following 
problems? 
a. Little interest or pleasure in doing things? 
Not at all:			
Few or several days: 
More than half the days: 	
Nearly every day: 

b. Feeling down, depressed, or hopeless? 
Not at all:			
Few or several days: 
More than half the days: 	
Nearly every day: 

12. If you checked off any problems or concerns on this questionnaire, 
how difficult have these problems made it for you to do your work, take 
care of things at home, or get along with other people? 
Not difficult at all: 
Somewhat difficult: 
Very difficult:	
Extremely difficult: 

13. Would you like to schedule a visit with a healthcare provider to 
further discuss your health concern(s)?	
Yes: 
No: 

14. Are you currently interested in receiving information or assistance 
for a stress, emotional or alcohol concern? 
Yes: 
No: 
		
15. Are you currently interested in receiving assistance for a family 
or relationship concern? 
Yes: 
No: 

16. Would you like to schedule a visit with a chaplain or a community 
support counselor? 
Yes: 
No: 

Health Care Provider Only: 

Service Member's Social Security Number: 
Date (dd/mm/yyyy): 

Provider Review and interview: 

1. Review symptoms and deployment concerns identified on form: 
Confirmed screening results as reported: 
Screening results modified, amended, clarified during interview: 

2. Ask behavioral risk questions. 
a. Over the Past Month, have you been bothered by thoughts that you 
would be better off dead or of hurting yourself in some way? 
Yes: 
No: 

If Yes, about how often have you been bothered by these	thoughts? 
Very few days: 
More than half of the time: 
Nearly every day: 
	
b. Since return from your deployment, have you had thoughts or concerns 
that you might hurt or lose control with someone? 
Yes: 
No: 
Unsure: 

3. If Yes Or Unsure to behavioral risk questions, conduct risk 
assessment. 
a. Does member pose a current risk for harm to self or others?	
No, not a current risk:	
Yes, poses a current risk: 
Unsure, referred: 

b. Outcome of assessment: 
Immediate referral: 
Routine follow-up referral: 
Referral not indicated: 
	
4. Record additional questions or concerns identified by patient during 
interview: 

Assessment and Referral: After my interview with the service member and 
review of this form, there is a need for further evaluation and follow-
up as indicated below. (More than one may be noted for patients with 
multiple concerns.) 

5. Identified Concerns: 

Physical Symptom: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Exposure Concern: 		
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 	 

Depression Symptoms: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

PTSD Symptoms: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Anger/Aggression: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Suicidal Ideation: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Social/Family Conflict: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Alcohol Use: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

Other: 
Minor Concern: 
Major Concern: 
Already Under Care, Yes: 
Already Under Care, No: 

None: 

6. Referral Information: 
a. No referral made: 
b. Immediate/emergent care: 
c. Primary Care, Family Practice: 
d. Specialty Care: 
e. Behavioral Health in Primary Care: 
f. Mental Health Specialty Care: 
g. Case Manager, Care Manager: 
h. Substance Abuse Program: 
i. Health Promotion, Health Education: 
j. Other Healthcare Service: 
k. Chaplain: 
l. Family Support, Community Service: 
m. Military OneSource: 
n. Other: 

7. Comments: 

8. Provider: 
a. Name {Last, First): 
b. Signature and stamp: 

ICD-9 Code for this visit: V70.5_6: 

Ancillary Staff/Administrative Section: 

9. Member was provided the following: 
Health Education and Information: 
Health Care Benefits and Resources Information: 
Appointment Assistance: 
Service member declined to complete form: 
Service member declined to complete interview/assessment: 
Service member declined referral for services: 
Other: 

10. Referral made to the following healthcare or support system: 
Military Treatment Facility: 
Division/Line-Based Medical Resource: 
VA Medical Center or Community Clinic: 
Vet Center: 
Tricare Provider: 
Contract Support: 
Community Service: 
Other: 
None: 

[End of enclosure] 

Enclosure 2: Comments from the Department of Defense: 

Comments from the Department of Defense: 

The Assistant Secretary Of Defense: 
Health Affairs: 
1200 Defense Pentagon: 
Washington, DC 20301-1200: 

January 3, 2008: 

Ms. Laurie E. Ekstrand: 
Director, Health Care: 
U.S. Government Accountability Office:
441 G Street, NW: 
Washington, DC 20548: 

Dear Ms. Ekstrand: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) draft report, GAO-08-181R, "VA and DoD 
Health Care: Administration of DoD's Post-Deployment Health 
Reassessment to National Guard and Reserve Service Members and VA's 
Interaction with DoD," dated November 9, 2007 (GAO Code 290600). 

Thank you for the opportunity to review the draft report. Overall, I 
concur with the draft report's findings and conclusions. However, I do 
wish to identify some additional information to help clarify portions 
of the report. The title clearly states that this report is limited to 
National Guard and Reserve Service members. However, the opening line 
of the report states, "For servicemembers who have deployedï¿½including 
National Guard and Reserveï¿½ ..." This establishes a total force mindset 
among the readers. Although a footnote defines "servicemembers," not 
everyone is diligent about reading footnotes, and it is not until the 
bottom of the second page that the report states, "Our work focused on 
National Guard (federally activated) and Reserve Service members..." To 
minimize confusion, I suggest clearly identifying the focus of the 
study in the opening paragraph of the report. Additional technical 
comments are attached for your consideration. 

The Department appreciates your review of this important matter to help 
ensure that the appropriate level of health care can be provided to the 
Service members who have so valiantly served their country. 

My points of contact on this issue are Colonel Kenneth Cox, Force 
Health Protection and Readiness (Functional) at (703) 575-2678, and Mr. 
Gunther Zimmerman (Audit Liaison) at (703) 681-4360. 

Sincerely, 

Signed by: 

S. Ward Casscells, MD 

Enclosure: As stated: 

Government Accountability Office Draft Report Dated November 9, 2007: 
Government Accountability Office-08-181R: 
(Government Accountability Office Code 290600): 
"VA and DoD Health Care: Administration of DoD's Post-Deployment Health
Reassessment to National Guard and Reserve Service members and VA's
Interaction with DoD" 

Department of Defense Comments Technical Comments: 

Page 2, "Recent congressional interest has centered on National Guard 
and Reserve Service members because they are being activated in numbers 
not seen since World War II and have reported post-deployment mental 
health concerns at a higher rate than their Active Duty counterparts." 
This cannot be generalized across all Services. 

Recommend: That the Government Accountability Office (GAO) modify the 
above narrative statement to accurately reflect that there are 
differences in the degree of elevation regarding mental health concerns 
in the Components. A suggested statement is provided below. 

"Recent congressional interest has centered on National Guard and 
Reserve Service members because they arc being activated in numbers not 
seen since World War II and have often reported post-deployment mental 
health concerns at a higher rate than their Active Duty counterparts, 
though the increase varies with the Component. For instance, the Air 
National Guard actually reports mental health concerns 1 percent less 
often than the Active Air Force, though this is not a significant 
difference. At the other extreme, the Army National Guard and Army 
Reserve Components report such concerns 10 percent more often than the 
Active Army." 

Page 9, "Following the telephone interview, call center personnel mail 
servicemembers a brochure about VA benefits for National Guard and 
Reserve servicemembers, a copy of their DD 2900 and contact information 
for the VA senior military liaison to assist them if they experience 
problems getting an appointment at a VA facility." 

Recommend: We suggest that GAO clarify the above narrative statement. A 
suggested revised statement is provided: "Following the telephone 
interview, call center personnel mail Service members a brochure about 
Veterans Affairs (VA) benefits for National Guard and Reserve Service 
members, a copy of their DD 2900, and contact information for the 
Military Liaison Coordinator in the VA Office of Seamless Transition to 
assist them if they experience problems getting an appointment at a VA 
facility." 

[End of enclosure] 

Enclosure 3: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Marjorie Kanof, (202) 512-7114 or [email protected]: 

Acknowledgments: 

In addition to the contact named above, key contributors to this report 
were James C. Musselwhite, Jr., Assistant Director; Rebecca Abela; 
Laurie E. Ekstrand; Hannah Fein; Cynthia Forbes; and Julianna Weigle. 

[End of enclosure] 

Related GAO Products: 

Defense Health Care: Comprehensive Oversight Framework Needed to Help 
Ensure Effective Implementation of a Deployment Health Quality 
Assurance Program. GAO-07-831. Washington, D.C.: June 22, 2007. 

VA and DOD Health Care: Efforts to Provide Seamless Transition of Care 
for OEF and OIF Servicemembers and Veterans. GAO-06-794R. Washington, 
D.C.: June 30, 2006. 

Post-Traumatic Stress Disorder: DOD Needs to Identify the Factors Its 
Providers Use to Make Mental Health Evaluation Referrals for 
Servicemembers. GAO-06-397. Washington, D.C.: May 11, 2006. 

VA and DOD Health Care: VA Has Policies and Outreach Efforts to Smooth 
Transition from DOD Health Care, but Sharing of Health Information 
Remains Limited. GAO-05-1052T. Washington, D.C.: September 28, 2005. 

Defense Health Care: Occupational and Environmental Health Surveillance 
Conducted During Deployments Needs Improvement. GAO-05-903T. 
Washington, D.C.: July 19, 2005. 

Defense Health Care: Improvements Needed in Occupational and 
Environmental Health Surveillance During Deployments to Address 
Immediate and Long-Term Health Issues. GAO-05-632. Washington, D.C.: 
July 14, 2005. 

Defense Health Care: Force Health Protection and Surveillance Policy 
Compliance Was Mixed, but Appears Better for Recent Deployments. GAO-
05-120. Washington, D.C.: November 12, 2004. 

Gulf War Illnesses: Federal Research Efforts Have Waned, and Research 
Findings Have Not Been Reassessed. GAO-04-815T. Washington, D.C.: June 
1, 2004. 

Department of Veterans Affairs: Federal Gulf War Illnesses Research 
Strategy Needs Reassessment. GAO-04-767. Washington, D.C.: June 1, 
2004. 

Defense Health Care: DOD Needs to Improve Force Health Protection and 
Surveillance Processes. GAO-04-158T. Washington, D.C.: October 16, 
2003. 

Defense Health Care: Quality Assurance Process Needed to Improve Force 
Health Protection and Surveillance. GAO-03-1041. Washington, D.C.: 
September 19, 2003. 

VA and Defense Health Care: Progress Made, but DOD Continues To Face 
Military Medical Surveillance System Challenges. GAO-02-377T. 
Washington, D.C.: January 24, 2002. 

VA and Defense Health Care: Progress and Challenges DOD Faces in 
Executing a Military Medical Surveillance System. GAO-02-173T. 
Washington, D.C.: October 16, 2001. 

[End of section] 

(290600)

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