# Attachment 1 **– Survey Instrument**  Postsecondary Education Quick Information System (PEQIS) 19 : Services and Support Programs for Military Service Members and Veterans, 2012– 13 OMB# 1850 - 0 73 3 v. 28

April 2, 2013 National Center for Education Statistics U.S. Department of EducationU.S. DEPARTMENT OF EDUCATION NATIONAL CENTER FOR EDUCATION STATISTICS

WASHINGTON, D.C. 20006 - 5651 **SERVICES AND SUPPORT PROGRAMS FOR MILITARY SERVICE MEMBERS AND VETERANS**  **, 2012** **– 13**  POSTSECONDARY EDUCAT ION QUICK INFORMATIO N SYSTEM FORM APPROVED O.M.B. No.: 1850–0733 EXPIRATION DATE: 05/2015 

### DRAFT 3 - 1 8 - 1 3 This survey is authorized by law (Education Sciences Reform Act of 2002, 20 U.S.C. 9543). While participation in this survey is voluntary, your cooperation is critical to make the results of this survey comprehensive, accurate, and timely. Your answers may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose unless othe rwise compelled by law (Education Sciences Reform Act of 2002, 20 U.S.C. 9573). 

### This survey

**should be completed by the person(s) most kno** **wledgeable about service**  **s and programs**  **for military**

**service members and veterans at your institution .**  **Please consult with others at your**  **institution who can help provide the requested information.** 

IF ABOVE INSTITUTION INFORMATION IS INCORRECT, PLEASE UPDATE DIRECTLY ON LABEL. Name of person completing this form:

____________________________ Telephone:

___________________________ Title/position:

________________________________ _______________ E - ma il:

_______________________________ Office/Department :

________________________________ ________________________________ _________________ Best days and times to reach you (in case of questions):

________________________________ ____________________ **THA NK YOU. PLEA** **SE KEEP A COPY OF THIS SURVEY FOR YOUR RECORDS.**  **PLEA SE RETURN COMPLETED FORM TO:**  **IF YOU HA VE A** **NY QUESTIONS, CONT AC**  **T: Ma**  **il:** Barbara Queen Barbara Queen at We stat We stat 800 - 937 - 8281 Ext. 4476 or 301 - 294 -4476 1600 Research Boulevard E - ma il: BarbaraQueen @westat.com Rockville, MD 20850 Fax: 800 - 254 - 0984 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 1850–0733. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments con cerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202–4537. If you have comments or concerns regarding the status of your individual submission of this fo rm , write directly to: PEQIS, National Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 20006. PEQIS Form No. 19, 04/2013

### Please read the following instructions and definitions below before answering the questions. For the purposes of this survey, the term **military service members and veterans** refers to active - duty service me mb ers, reservists, members of the National Guard , and veterans . Please report about services and programs offered to **all** mi litary service membe rs and veterans enrolled for credit at yo ur institution. Include those who receive military or veteran’s financial education benefits and those who do not receive financial education benefits but self- identify to the institution in another way. Please in clude **dependents** of military service members and veterans who are receiving military or veteran’s financial education benefits . Except where indicated, questions refer to the **12 -**  **month 2012 –**  **13 academic year** . This includes the summer of 2012 or the summer of 2013, depending upon how records are kept at your institution. 1 . D id yo ur institution enroll any military service members, veterans, or dependents of military service members and veterans d uring the 12 - mo nth 2012 - 13 academic year? ( See instructions and definitions box above.) Yes No (Stop. Complete respondent section on front and return survey.) 2 . D oes yo ur institution use any of the following ways to identify students who are mi litary service members and veterans ? (

Indicate yes or no for each item.) **Yes No**  a. Receipt of state or Federal military and veterans educational benefits ................................ ................. b . Questions on the admissions application ................................ ................................ ............................... c. Student self- identification other than the admissions application ( specify)

_____________________ 3 . D oes yo ur institution have a dedicated social space for gathering (e.g., a student lounge) reserved specifically for mi litary service members and veterans ? Yes No 4 . Does your institution have a student military or veteran organization for students who are military service members or veterans ? Yes No 5 . Is there college/ university owned or operated housing ( on or off- cam pus ) reserved specifically for mi litary service me mb ers and veterans ? Yes No 6 . Does your institution provide customized information to individual mi litary service members and v eterans about both the mi litary and non - mi litary financial education benefits available to them? (Customized information may include one on -one session s to review financial education benefits .) Yes No 7 . Does your institution have a staff member or office designated as the point of contact for military service membe rs and veterans seeking information on the programs and services available to them? (Only include the V eterans A ffairs (VA) certifying official if that person also provides information to military service members and veterans about programs and services av ailable to them .) Yes No 8 . Does your institution offer any courses (or sections of courses) specifically for military service members and veterans ? (Do not include military science or ROTC courses.) Yes No 9 . Does your institution award academic credit to students for military training received during active - duty service? ( Include credit awarded on a case -by - case basis.) Yes No 1 0 . Does your institution provide admissions events or special adm issions information sessions customized for prospective students who are military service members or veterans? Yes No1 1 . Does yo ur institution customize your student orientation program for military service members and veterans?

(Customization may include offering breakout sessions specifically for military service members and veterans during yo ur student orientation program .) Yes No 12. Does your institution have a formal mentoring or advising program in which faculty or staff members who are current or former members of the military mentor students who are military service members or veterans? Yes No 1 3 . Does your institution have a veteran -to -veteran peer mentoring program for students who are military service me mb ers or veterans? Yes No 1 4 . Does your institution offer group counseling specifically for students who are military se rvice members or veterans? Yes No 1 5 . Does your institution offer **customized or additional**  support services specifically for mi litary service members and veterans in the following areas ? (Only report about additional or customized support services beyond those usually provided to students taking courses through your institution . Indicate yes or no for each item .) **Yes No**  a. Academic support/t utoring ................................ ................................ ................................ ...................... b. Academic advising ................................ ................................ ................................ ................................ . c. Stud y skills workshops ................................ ................................ ................................ ........................... d. Assista nce finding non work- study employment ................................ ................................ .................... e. Financial aid counseling ................................ ................................ ................................ ......................... f. Career planning/services ................................ ................................ ................................ ........................ g . Mental health counseling ................................ ................................ ................................ ........................ h . Som e other support service(s) ( specify)

________________________________ ________________ 1 6 . Does your institution provide information about or referrals for the following types of off- cam pus health - related services for mi litary service members or veterans? (Indicate yes or no for each item.) **Yes No**  a. Medical/health services ................................ ................................ ................................ .......................... b. Counseling or mental health services ................................ ................................ ................................ .... 1 7 . Please indicate in **part 1** whether your institution offers **training for faculty or staff** in the following areas . For each area of training that your institution offers, please indicate in **part 2**  whether the train ing is mandatory for faculty or staff. **Area of training Part 1**  **. Institution**  **offers training for faculty**  **or staff? Part**  **2 .**  **If offered, is**

**training mandatory for faculty** 

**or staff?** a. Mental health issues associated with military service Yes No Yes No b . Ph ys ical health issues resulting from military service Yes No Yes No c . Student transition from military life to civilian life Yes No Yes No 1 8 . How does your institution provide information to current or prospective students about the programs and services available to mi litary service members and veterans at your institution ? (Indicate yes or no for each item.) **Yes No**  a. Mail ................................ ................................ ................................ ................................ ......................... b. Em ail ................................ ................................ ................................ ................................ ....................... c . We bsite ................................ ................................ ................................ ................................ ................... d . Social m edia (e.g., Facebook, Twitter) ................................ ................................ ................................ ... e . B rochures ................................ ................................ ................................ ................................ ............... f . Bulletin boards ................................ ................................ ................................ ................................ ........ 19. D oes your institution provide information to prospective students at the following types of events about the programs and services available to military service members and veterans at your institution ? (Indicate yes or no for each item.) **Yes No**  a . College adm issio ns fairs ................................ ................................ ................................ ........................ b . Information fairs/events held on military ba ses ................................ ................................ ......................20 . In the last 12 months, has your institution helped students apply for tutorial assistance using VA educational benefits?

Yes No 21 . Does your institution offer VA work- study opportunities? Yes No 22. Are veterans exempt from paying tuition at your institution ? Yes (

Skip to question 24 .) No (Continue with question 23.) 2 3 . W hich of the following describe your institution’s policy for charging veterans **in -** **state** tuition rates? ( For this question, **e xclude**  **active -**  **duty** personnel stationed in your state. Indicate yes or no for each item.) If in -state tuition does not apply to your institution, check here and skip to question 24 . **Yes No**  a. Veterans who currently reside in the state receive in - state tuition rates regardless of length of residency ................................ ................................ ................................ ................................ . b . Veterans who previously resided in the state and were stationed elsewhere receive in - state tuition rates immediately upon return to the state ................................ ................................ ..... c . Veterans who ma intained the state as their home of record during active - duty service receive in - state tuition rates ................................ ................................ ................................ ................... 

### Questions **2 4** **– 2**  **8 refer to the fall of 2012. Please**  **refer to the instructions a nd definitions at the beginning**  **of the questionnaire as needed**  **.** 2 4 . During the **fall of 2012** , did yo ur institution enroll any military service members, veteran s , or dependents of military service members and veterans? Yes No (Stop. Complete respondent section on front and return survey.) 2 5 . During the **fall of 2012** , how many military service members and veterans, and dependents of military service me mb ers and veterans were enrolled in your institution? ( For dependents, only include those who received military or veteran’s financial education benefits.) a. Number enrolled at the undergraduate level

___________ b. Number enrolled at the graduate level

___________ 2 6 . Wh ich of the followi ng types of students are included in the enrollment counts reported at question 2 5 ? (Indicate yes or no for each item.) **Yes No**  a. Active - duty

service members , reservists , and members of the National Guard who received mi litary financial education benefits ................................ ................................ ................. b. Veterans who received veteran’s financial education benefits ................................ .............................. c. Dependents of military service members and veterans who received military or veteran’s financial education benefits ................................ ................................ ................................ .................... d . Military service members and veterans who self- identified as military service members or veterans but did not receive mi litary or veteran’s financial education benefits ................................ . 2 7 . How ma ny

of the students reported at question 2 5 are **dependents** of military service members or veterans who received military or veteran’s financial education benefits? If your institution do es not track enrollments separately for dependents of military service members and veterans, check here . You’ve reached the end of the survey. Complete respondent section on front and return survey. a. Number of dependents enrolled at the undergraduate level

___________ b. Number of dependents enrolled at the graduate level

___________ 28. Wh ich of the following types of **dependents** are included in the enrollment counts reported at **question 27** ? (Indicate yes or no for each item.) **Yes No**  a. Dependents who received transferred benefits under Chapter 33 (Post 9/11 GI Bill) ........................... b. Dependents who received benefits under Chapter 35 (Survivors and Dependents Benefits) ............... c. Dependents who received other types of military or veteran’s financial education benefits (specify type)

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