DOD policy states that each military service must administer the PDHRA to active component, Reserve component, and separated servicemembers 90 to 180 days following deployment if they meet the following conditions: deployed for greater than 30 days, deployed to locations outside the continental United States, and deployed to locations without permanent military treatment facilities. The military services, using service-specific databases, identify active and Reserve component servicemembers to whom the PDHRA requirement applies and notify these servicemembers via various methods, such as postcards, e-mail, telephone, and face-to-face contact. The DOD policy that initiated the PDHRA program stated that the military services should contact servicemembers who separate before or during the reassessment period to offer them the opportunity to fill out the PDHRA questionnaire. However, there is no mechanism in place to offer separated servicemembers the opportunity to fill out the PDHRA questionnaire. Once these servicemembers have separated from military service, they have no further obligation to the military services and accordingly, cannot be required to fill out the PDHRA questionnaire. It can also be difficult to locate and contact servicemembers after they separate. Instead, the military services, with the exception of the Air Force, implemented policies to administer the PDHRA to active and Reserve component servicemembers as part of the separation process from the military. Although the Army formally implemented its policy to administer the PDHRA to servicemembers before they separate in April 2008, the practice had been in effect as early as January 2006. The Navy and Marine Corps implemented a similar policy in January 2009. According to Air Force officials, there are plans to implement a policy by December 2009. The PDHRA involves two steps—active or Reserve component servicemembers fill out a PDHRA questionnaire and then discuss their questionnaire health concern responses with health care providers. The PDHRA questionnaire consists of a demographic section, a medical section, and a third section for a health care provider to fill out and sign. The demographic section asks for servicemembers to provide information such as date of birth, gender, and marital status. The medical section of the questionnaire asks servicemembers to self-report information on their current physical and mental health condition and concerns. DOD considers a PDHRA questionnaire complete when a health care provider reviews and signs the questionnaire, regardless of whether servicemembers fill out the entire PDHRA questionnaire or only the demographic section. (See app. II for a sample PDHRA questionnaire.) The Army, Air Force, Navy, and Marine Corps require active and Reserve component servicemembers to whom the PDHRA requirement applies to fill out at least the demographic section of the PDHRA questionnaire. Although filling out the medical section is voluntary, DOD officials estimate that less than 1 percent of servicemembers who fill out the PDHRA questionnaire decline to fill out the medical section, with the exception of the Air Force, which reported a higher declination rate. Active component servicemembers typically fill out the PDHRA questionnaire online either prior to PDHRA on-site events or during such events, which are usually held at military installations. Similarly, Reserve component servicemembers may fill out the PDHRA questionnaire— administered by the contractor, LHI—online, prior to or during on-site events. In addition, LHI maintains call centers to administer the PDHRA to Reserve component servicemembers. Reserve component servicemembers who use LHI’s call centers may fill out the demographic and medical sections of the questionnaire online or, with the help of call center staff, may fill out both sections of the questionnaire through the call centers. DOD requires that a health care provider review and discuss active and Reserve component servicemembers’ health concern responses on the PDHRA questionnaire, including any physical and mental health concerns that servicemembers self-identify on their questionnaires. Health care providers use professional judgment to decide whether a further evaluation is needed, based on servicemembers’ responses and other information revealed from the discussions with servicemembers. If referrals for a further evaluation are recommended, health care providers offer servicemembers information on obtaining a referral appointment. For example, a health care provider may provide information on obtaining an appointment at a military treatment facility or a Vet Center. Once a referral for a further evaluation is made, DOD does not require the military services to follow up to determine if active and Reserve component servicemembers have made or attended an appointment generated as a result of the health care provider’s assessment. However, for Reserve component servicemembers, referral follow-up is part of LHI’s administration of the PDHRA. LHI staff follow up within 72 hours with Reserve component servicemembers who have been issued a referral for a further evaluation through the call centers to ensure that these servicemembers have the information needed to obtain an appointment and to encourage servicemembers to schedule an appointment. In addition, LHI staff attempt to contact Reserve component servicemembers 30 days after medical referrals are issued, whether issued through PDHRA on-site events or through the call centers, to ask whether they scheduled and attended an appointment. If servicemembers did not, LHI staff ask if assistance is needed in scheduling an appointment. Each of the military services is required to electronically submit PDHRA questionnaires for both active and Reserve component servicemembers to DOD’s central repository. The central repository is the single source of DOD-level health surveillance information. The central repository contains data on diseases and medical events and longitudinal data on personnel and deployments, including information from DOD’s various deployment health assessments, such as the PDHRA. For Reserve component servicemembers who fill out PDHRA questionnaires through LHI, LHI staff are responsible for verifying that the questionnaires are submitted to the appropriate military service’s database. The military services are then responsible for submitting the questionnaires from their respective databases to DOD’s central repository. DOD established a deployment health quality assurance program in January 2004 to assess whether DOD’s deployment health assessments, including the PDHRA, are conducted as required. The deployment health quality assurance program relies on data from DOD’s central repository, data from the military services, and site visits to military installations to monitor and report on the extent of compliance among the military services with DOD’s deployment health requirements, such as the number of active and Reserve component servicemembers that filled out the PDHRA questionnaire. According to DOD’s deployment health quality assurance program manager, the program performed a site visit to Reserve units to validate data provided by the military services for the first time in October 2008, as part of its oversight of deployment health assessments, including the PDHRA. Prior to that, the quality assurance program only performed site visits to active component sites. On a quarterly basis, the quality assurance program reports to the military services on each service’s compliance with deployment health requirements. The quality assurance program also reports annually to the Armed Services Committees of the House of Representatives and Senate on site visit findings and on deployment health assessment data, including the number and percentage of servicemembers with PDHRA questionnaires in DOD’s central repository. Through its monitoring and reporting, DOD’s quality assurance program helps ensure that DOD’s deployment health assessments are conducted for active and Reserve component servicemembers as required. DOD contracts with LHI to administer the PDHRA to Reserve component servicemembers. Although LHI administers the PDHRA to Reserve component servicemembers on behalf of DOD, the military services are responsible for identifying and notifying servicemembers to whom the PDHRA requirement applies and for submitting questionnaires to DOD’s central repository. DOD’s RHRP office is responsible for monitoring DOD’s contract with LHI, which includes the administration of the PDHRA to Reserve component servicemembers, as well as the provision of other health services for this population, such as immunizations, physical examinations, and dental examinations and X-rays. DOD’s contract with LHI is a performance-based contract and, as such, establishes performance standards that the RHRP office uses in monitoring and assessing LHI’s performance in providing services to Reserve component servicemembers, including the administration of the PDHRA. For example, under its contract with DOD, LHI call center staff are required to answer 80 percent of incoming calls within 120 seconds. In monitoring LHI’s performance, DOD’s RHRP office helps ensure that the objective of the PDHRA program—to identify and address servicemembers’ health concerns, including mental health concerns, that emerge over time following deployments—is achieved for Reserve component servicemembers. On the two occasions we queried DOD’s central repository, we did not find PDHRA questionnaires for a substantial percentage of the active and Reserve component servicemembers in our population of interest. DOD policy requires that the military services electronically submit questionnaires to DOD’s central repository, which DOD uses as a key source of health surveillance information. The first of our two queries of DOD’s central repository occurred on April 15, 2009. On this date, we found that the central repository contained PDHRA questionnaires for only 77 percent of the roughly 319,000 active component, Reserve, and National Guard servicemembers who, according to DOD DMDC deployment data, returned from deployment to Iraq or Afghanistan between January 1, 2007, and May 31, 2008.