Attachment 1 – Survey Instrument

Postsecondary Education Quick Information System 

(PEQIS) 19: Services and Support Programs for Military 

Service Members and Veterans, 2012–13

OMB# 1850-0733 v. 28

April 2, 2013

National Center for Education Statistics

U.S. Department of Education
U.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 EDUCATION QUICK INFORMATION SYSTEM

FORM APPROVED

O.M.B. No.: 1850–0733

EXPIRATION DATE: 05/2015

DRAFT

3-18-13

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 otherwise compelled by law (Education Sciences Reform Act of 

2002, 20 U.S.C. 9573). 

This survey should be completed by the person(s) most knowledgeable about services 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-mail:_______________________________

Office/Department: _________________________________________________________________________________

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

THANK YOU. PLEASE KEEP A COPY OF THIS SURVEY FOR YOUR RECORDS.

PLEASE RETURN COMPLETED FORM TO: IF YOU HAVE ANY QUESTIONS, CONTACT:

Mail: Barbara Queen Barbara Queen at Westat

Westat 800-937-8281 Ext. 4476 or 301-294-4476

1600 Research Boulevard E-mail: 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 concerning 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 form, 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 

members, reservists, members of the National Guard, and veterans.

Please report about services and programs offered to all military service members and veterans enrolled for credit at 

your 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 include 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. Did your institution enroll any military service members, veterans, or dependents of military service members and 

veterans during the 12-month 2012-13 academic year? (See instructions and definitions box above.)

Yes No (Stop. Complete respondent section on front and return survey.)

2. Does your institution use any of the following ways to identify students who are military 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. Does your institution have a dedicated social space for gathering (e.g., a student lounge) reserved specifically for 

military 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-campus) reserved specifically for military service 

members and veterans? 

Yes No 

6. Does your institution provide customized information to individual military service members and veterans about both 

the military and non-military financial education benefits available to them? (Customized information may include oneon-one sessions 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 members 

and veterans seeking information on the programs and services available to them? (Only include the Veterans Affairs 

(VA) certifying official if that person also provides information to military service members and veterans about 

programs and services available 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 

10. Does your institution provide admissions events or special admissions information sessions customized for 

prospective students who are military service members or veterans? 

Yes No 
11. Does your 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 

your 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 

13. Does your institution have a veteran-to-veteran peer mentoring program for students who are military service 

members or veterans? 

Yes No 

14. Does your institution offer group counseling specifically for students who are military service members or veterans? 

Yes No 

15. Does your institution offer customized or additional support services specifically for military 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/tutoring......................................................................................................................

b. Academic advising .................................................................................................................................

c. Study skills workshops ...........................................................................................................................

d. Assistance finding non work-study employment ....................................................................................

e. Financial aid counseling .........................................................................................................................

f. Career planning/services........................................................................................................................

g. Mental health counseling........................................................................................................................

h. Some other support service(s) (specify)________________________________________________

16. Does your institution provide information about or referrals for the following types of off-campus health-related 

services for military service members or veterans? (Indicate yes or no for each item.)

Yes No

a. Medical/health services ..........................................................................................................................

b. Counseling or mental health services ....................................................................................................

17. 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 training 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. Physical health issues resulting from military service Yes No Yes No

c. Student transition from military life to civilian life Yes No Yes No

18. How does your institution provide information to current or prospective students 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. Mail .........................................................................................................................................................

b. Email.......................................................................................................................................................

c. Website...................................................................................................................................................

d. Social media (e.g., Facebook, Twitter)...................................................................................................

e. Brochures ...............................................................................................................................................

f. Bulletin boards........................................................................................................................................

19. Does 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 admissions fairs ........................................................................................................................

b. Information fairs/events held on military bases ......................................................................................
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.)

23. Which of the following describe your institution’s policy for charging veterans in-state tuition rates? (For this question, 

exclude 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 maintained the state as their home of record during active-duty service 

receive in-state tuition rates ...................................................................................................................

Questions 24–28 refer to the fall of 2012. Please refer to the instructions and definitions at the beginning 

of the questionnaire as needed. 

24. During the fall of 2012, did your institution enroll any military service members, veterans, or dependents of military 

service members and veterans? 

Yes No (Stop. Complete respondent section on front and return survey.)

25. During the fall of 2012, how many military service members and veterans, and dependents of military service 

members 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 ___________

26. Which of the following types of students are included in the enrollment counts reported at question 25? (Indicate yes 

or no for each item.)

Yes No

a. Active-duty service members, reservists, and members of the National Guard

who received military 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 military or veteran’s financial education benefits .................................

27. How many of the students reported at question 25 are dependents of military service members or veterans who

received military or veteran’s financial education benefits?

If your institution does 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. Which 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) _____________________________________________________________