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Deployment Health Reassessment Completion Rates Is Limited' which was 
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GAO-08-1025R: 

United States Government Accountability Office: 
Washington, DC 20548: 

September 4, 2008: 

Congressional Addressees: 

Subject: Defense Health Care: Oversight of Military Services' Post- 
Deployment Health Reassessment Completion Rates Is Limited: 

Military servicemembers engaged in combat tours in Afghanistan and Iraq 
are at risk of developing combat-related mental health conditions, 
including post-traumatic stress disorder (PTSD). In many cases, signs 
of potential mental health conditions do not surface until months after 
servicemembers return from deployment. In 2004, Army researchers 
published a series of articles that indicated a significant increase in 
the number of servicemembers reporting mental health concerns 90 to 120 
days after returning from deployment, compared with mental health 
concerns reported before or soon after deployment.[Footnote 1] These 
findings led the Department of Defense (DOD) in March 2005 to develop 
requirements and policies for the post-deployment health reassessment 
(PDHRA) as part of its continuum of deployment health assessments for 
servicemembers. PDHRA is a screening tool for military servicemembers; 
it is designed to identify and address their health concerns--including 
mental health concerns--90 to 180 days after return from deployment. 
Servicemembers answer a set of questions about their physical and 
mental health conditions and concerns, and health care providers review 
the answers and refer servicemembers for further evaluation and 
treatment if necessary. A November 2007 study showed that a larger 
number of servicemembers indicated mental health concerns on their 
PDHRAs than on assessments earlier in their deployment cycles.[Footnote 
2] 

Although DOD established PDHRA requirements and policies, it gave the 
military services discretion to implement them to meet their unique 
needs as long as the services adhere to the requirements and policies. 
DOD oversees the military services' compliance with PDHRA requirements 
through its deployment health assessment quality assurance program and 
is required to report on the quality assurance program annually to the 
Armed Services Committees of the House of Representatives and Senate. 
[Footnote 3] In June 2007, we reported that DOD's oversight of its 
deployment health assessments does not provide DOD or Congress with the 
information needed to evaluate DOD and the military services' 
compliance with deployment health assessment requirements.[Footnote 4] 
That report is part of a body of work in which we identified weaknesses 
in DOD's quality assurance program.[Footnote 5] 

The Senate Committee on Armed Services directed us to review DOD's 
oversight of PDHRA, and the House Committee on Armed Services and 11 
senators also expressed interest in this work.[Footnote 6] In this 
report, we focus on how DOD ensures that servicemembers complete the 
PDHRA.[Footnote 7] Specifically, we discuss how well DOD's quality 
assurance program oversees the military services' compliance with the 
requirement that they ensure that servicemembers complete the PDHRA. 

To evaluate how well DOD's quality assurance program oversees the 
military services' compliance with the requirement that they ensure 
servicemembers complete the PDHRA, we reviewed DOD's policies for PDHRA 
and its deployment health assessment quality assurance program. 
[Footnote 8] We also reviewed our June 2007 report on the 
implementation of DOD's quality assurance program, which is based on 
2005 and 2006 data. We interviewed officials from DOD and the military 
services to determine whether the process and procedures DOD's quality 
assurance program uses to oversee the military services' compliance 
with deployment health assessments have changed since our 2007 report. 
In addition, we analyzed all quarterly reports submitted to DOD's 
quality assurance program from the four services for 2007. We also 
analyzed the four reports the military services submitted to DOD's 
quality assurance program for the first quarter of 2008, and the July 
2008 monthly report from the Armed Forces Health Surveillance Center 
(AFHSC).[Footnote 9] All of these reports are submitted to DOD's 
quality assurance program. Furthermore, we used these interviews and 
documents to gain additional knowledge of and clarification on the 
instructions and guidance for PDHRA. 

We conducted our work from February 2008 through July 2008, in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives. 

Results in Brief: 

DOD's quality assurance program has limitations and does not allow the 
department to accurately assess whether the military services ensure 
that servicemembers complete the PDHRA. DOD's quality assurance program 
relies on quarterly reports from each military service, monthly reports 
from AFHSC, and site visits to military installations to oversee the 
military services' compliance with deployment health assessment 
requirements, including completion of PDHRA. Each of these sources of 
information has limitations. The military services' quarterly reports 
and the monthly reports from AFHSC do not provide the information DOD 
needs to accurately assess the military services' PDHRA completion 
rates, which would allow DOD to determine if the military services have 
ensured that servicemembers completed the PDHRA. These reports do not 
allow DOD to calculate a completion rate because they do not provide 
essential information, such as the total number of servicemembers who 
returned from deployment and should have completed the PDHRA in that 
quarter or month. Furthermore, DOD cannot use information collected 
from site visits to validate the services' quarterly reports because 
the small number of site visits constitutes an insufficient sample for 
validation purposes. In our 2007 report, we recommended that DOD make 
enhancements to its quality assurance program, which would allow the 
department to better evaluate compliance with deployment health 
requirements. Although DOD concurred with the recommendation included 
in the 2007 report, as of June 2008, the department had not implemented 
the recommendation. As a result, DOD's quality assurance program cannot 
provide decision makers with reasonable assurance that servicemembers 
complete PDHRA. 

Overall, DOD concurred with our report's findings and conclusions; 
however, DOD identified several items in the report that it addressed 
in written comments. DOD suggested that the function of oversight is 
beyond the scope of the quality assurance program. Additionally, DOD 
commented that the department is taking steps that it believes will 
resolve some of the issues we note in this report. However, DOD did not 
provide us with relevant details or evidence pertaining to these 
efforts. We believe that oversight is an essential function of the 
quality assurance program and that the program currently does not 
receive the information necessary to perform this function. 

Background: 

Screenings and assessments of servicemembers' physical and mental 
health status are to occur at several times during the deployment 
cycle. These assessments are the pre-deployment health assessment, the 
post-deployment health assessment (PDHA), and PDHRA. (See enclosure I 
for a description of the purpose and timing of these assessments.) 

DOD developed requirements that all military services must follow when 
administering the PDHRA, although DOD allows the military services 
flexibility in administering the assessment based on their unique needs 
and organizations. In administering the PDHRA, all services use a 
standardized form that contains demographic and health care screening 
questions. The health screening questions focus on servicemembers' 
current physical and mental health conditions and concerns. (See 
enclosure II for a copy of the PDHRA form.) Servicemembers are given 
the option of answering the health screening questions. DOD's PDHRA 
requirements are:[Footnote 10] 

* Military services must ensure that servicemembers complete the PDHRA 
within 90 to 180 days after returning from deployment.[Footnote 11] DOD 
has designated the PDHRA as a "commander program," meaning that unit 
commanders at military installations are responsible for ensuring that 
their servicemembers complete PDHRAs within this time frame. 

* Servicemembers' PDHRA forms are to be reviewed by a health care 
provider--including primary care physicians, physician assistants, and 
nurse practitioners--who must certify that the assessments were 
reviewed by signing the form. 

* Health care providers are to interview servicemembers who report any 
health concerns on their PDHRA forms. 

* After the PDHRA form is reviewed, it is to be placed in a 
servicemember's military health record. A copy of the completed PDHRA 
form is also to be submitted electronically by the military services to 
DOD's Defense Medical Surveillance System (DMSS). The system is a 
central repository of medical surveillance data for the U.S. armed 
forces that is operated by AFHSC. 

DOD established a deployment health quality assurance program in 
January 2004 to ensure that servicemembers receive deployment health 
assessments as required.[Footnote 12] Although DOD's program predates 
the PDHRA, DOD uses the quality assurance program to oversee compliance 
with PDHRA requirements.[Footnote 13] As of June 2008, DOD's quality 
assurance program was staffed with one full-time equivalent position. 
[Footnote 14] 

DOD'S Deployment Health Quality Assurance Program Cannot Accurately 
Assess Military Services' PDHRA Completion Rates: 

DOD's quality assurance program relies on multiple sources of data to 
oversee the military services' compliance with deployment health 
requirements, including completion of PDHRAs. Taken individually or as 
a whole, these data do not allow the department to accurately assess 
whether PDHRAs are being completed. 

The military services' quarterly reports to DOD's quality assurance 
program do not provide the information DOD needs to accurately assess 
PDHRA completion rates for each of the military services. DOD's quality 
assurance policy requires the services to report (1) the number of 
servicemembers who deployed and returned from deployment and (2) the 
number of post-deployment health assessments completed, including 
PDHRAs. This information is essential to help DOD accurately determine 
completion rates of PDHRAs, as well as other deployment health 
assessments, across the military services. In our 2007 report, we 
recommended that the Assistant Secretary of Defense for Health Affairs 
enforce the requirement for the services to provide consistent 
information on all deployment health requirements on a quarterly basis. 
Although DOD concurred, we found that the data included in the 
quarterly reports for 2007 and the first quarter of 2008 remain 
inconsistent and incomplete. 

Because DOD does not provide specific standards for collecting and 
reporting this required information, there are inconsistencies within a 
service and among the services in what information is included in each 
quarterly report. For example, we found inconsistencies within the 
Army's four quarterly reports for 2007: 

* In the first quarter, the Army reported on samples ranging from 30 to 
50 servicemembers who should have completed the PDHRA at eight 
installations. 

* The second quarter report included information on a sample of 91 
servicemembers who should have completed the PDHRA at one installation. 

* In its third quarter report, the Army did not include any information 
on deployment health assessments, including PDHRA, citing time 
constraints, competing events, and personnel changes. 

* The fourth quarter report included information on deployment health 
assessments, except for PDHRA, for a sample of 143 servicemembers at 
one installation. An Army official told us that these servicemembers 
had recently returned from deployment and were not in the 90 to 180 day 
time frame for completing the PDHRA. 

Additionally, information included in the quarterly reports varies 
among the services. For example, in contrast to the Army's quarterly 
reports, we found that the Air Force did not include PDHRA in its 
quarterly reports for 2007. In its 2008 first quarter report, the Air 
Force reported on the aggregate number--over 50,000--of all of its 
servicemembers who had returned from deployment and should have 
completed PDHRAs since March 2004. Additionally, the military services 
do not consistently include PDHRA in their quarterly reports. For 
example, 6 of the 16 2007 quarterly reports that we reviewed did not 
include any information on the PDHRA. The absence of such data hampers 
the department's ability to compare compliance across the military 
services and within each military service across time. The DOD quality 
assurance program manager told us that she was aware of the 
inconsistencies in the military services' quarterly reports and said 
that she does not have the authority to enforce the two reporting 
requirements for the military services' quarterly reports. 

Additionally, AFHSC is required to report monthly to DOD's quality 
assurance program on servicemembers' deployment health assessments, 
including PDHRAs, but as of June 2008, these reports did not include 
all of the information DOD's quality assurance program needs to 
accurately assess PDHRA completion rates. These reports include the 
number of servicemembers who have completed the health assessment. This 
number is based on the number of completed PDHRAs submitted by each 
military service to AFHSC's DMSS database. As we reported in 2007, DOD 
does not require AFHSC to report the number of servicemembers who 
should have completed deployment health assessments.[Footnote 15] As a 
result, we recommended in 2007 that DOD provide AFHSC with specific 
reporting requirements for the reports, which would include identifying 
the total number of servicemembers who returned from deployment and who 
should have completed PDHRAs. In its comments, DOD stated that it would 
work with AFHSC to specify reporting requirements, such as the total 
number of servicemembers who returned from deployment, in order to get 
a more accurate picture of compliance. However, as of June 2008, the 
department had not specified reporting requirements for AFHSC's 
reports. 

While the quality assurance program manager does not obtain the total 
number of servicemembers who returned from deployment from AFHSC, the 
PDHRA program manager determines this number using a DOD database. 
Using this number and the number of completed PDHRAs from AFHSC, the 
PDHRA program manager determines a PDHRA completion rate for each 
service and makes this information available to the DOD quality 
assurance program manager. However, service-wide PDHRA completion rates 
are not included in DOD's quality assurance program's annual report to 
DOD and Congress. 

The DOD quality assurance program manager conducts a site visit to one 
installation per service per year to validate whether the information 
that the military services provide in their quarterly reports is 
correct, but we believe findings from the site visits, as currently 
conducted, should not be used for this purpose.[Footnote 16] During the 
site visits, servicemembers' medical records are reviewed to determine 
whether the required deployment health assessments, including PDHRAs, 
are in these records. Since the PDHRA is a commander program, the 
implementation can vary from one installation to another within a 
service, depending on an installation's unique needs and resources. 
Because of this potential variation among installations, DOD's quality 
assurance program cannot use one installation as a sufficient sample 
for validation of the information the military services include in 
their quarterly reports. 

Agency Comments and Our Evaluation: 

DOD reviewed a draft of this report and provided written comments, 
which appear in enclosure III. Overall, DOD concurred with our report's 
findings and conclusions and identified several items in the report 
that DOD addressed in its written comments. 

DOD suggested that oversight can include supervision or management, and 
consequently, this function would be beyond the scope of a quality 
assurance program. DOD noted that the actual management and execution 
of PDHRAs are the responsibility of commanders and the Military Health 
System. We acknowledge in our report that commanders bear 
responsibility for implementing the program. However, DOD's quality 
assurance program is required by statute to evaluate the success of 
DOD's deployment health assessment system in ensuring that 
servicemembers receive these assessments. PDHRA is one of DOD's 
deployment health assessments, and as such, we believe oversight is an 
important part of evaluating the success of the system. 

DOD stated that the key to assessing PDHRA compliance across the 
services is to ensure that the military services provide complete and 
accurate information to DOD's enterprisewide systems of record. To that 
end, DOD stated that it is working to develop high quality data feeds 
from the military services to DOD's databases that contain its systems 
of record and that DOD continues to work on improving the completeness 
and accuracy of the military services' data. However, DOD did not 
provide relevant details pertaining to these efforts or set a date by 
which these efforts are to be fully implemented. Therefore, it is 
essential that the quality assurance program receives complete and 
accurate information from the services in their quarterly reports in 
order to assess PDHRA completion rates and report them to decision 
makers. 

Also, DOD stated that site visits are not conducted to validate 
information provided in the services' quarterly reports, but are 
intended to allow DOD to understand the military services' operations 
and to provide staff assistance in a nonthreatening fashion. However, 
DOD's 2004 quality assurance program policy establishes that site 
visits are intended to complement and validate service deployment 
health quality assurance program reports. Although an additional policy 
of the quality assurance program was issued in 2007, it explicitly 
states that it expands deployment health quality assurance activities 
pursuant to the 2004 policy. The 2007 policy states that periodic on- 
site visits and reviews may serve as monitoring mechanisms for 
deployment health assessments. We stated in this report that the site 
visits as currently conducted should not be used for validation 
purposes. As DOD acknowledged, its site visits cannot possibly provide 
the volume of data necessary to validate the information contained in 
the services' databases. 

DOD pointed out that given the differences of combat and operations 
among the services, it is unlikely that the quarterly reports from each 
service would ever look the same over time. The flexibility afforded to 
each service in its quarterly reports is noted in this report. However, 
we maintain that each quarterly report should contain consistent 
information on all deployment health assessments that can be used by 
DOD's quality assurance program to help DOD accurately determine 
completion rates of deployment health assessments across the military 
services. 

In comments to our June 2007 report, DOD agreed with our recommendation 
to provide specific reporting requirements to the Army Medical 
Surveillance Activity (AFHSC's title prior to February 2008). DOD has 
now stated that AFHSC has developed a detailed compliance methodology 
using DOD-level data sources, and as a result, there is no need to 
modify AFHSC's reporting requirements. At the time of our 2008 review, 
DOD asserted that the compliance method was being performed by the 
PDHRA program manager and not through AFHSC, as we noted in this 2008 
report. In commenting, DOD did not provide relevant details or evidence 
pertaining to this effort. We maintain that AFHSC's monthly reports to 
DOD's quality assurance program should include the information 
necessary, including the total number of servicemembers who returned 
from deployment and should have completed PDHRAs, in order for the 
quality assurance program to accurately assess and report PDHRA 
completion rates to decision makers. 

In response to our statement that deployment health assessments are 
used for surveillance purposes, DOD responded that all deployment 
health assessments are primarily intended to maintain or improve 
servicemembers' health and incidentally used for surveillance purposes. 
We made changes in our report as appropriate to reflect this. 

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

If you or your staff have any questions about this report, please 
contact me at (202) 512-7114 or williamsonr@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made major contributions 
to this report are listed in enclosure IV. 

Signed by: 

Randall B. Williamson: 
Director, Health Care: 

List of Congressional Addressees: 

The Honorable Carl Levin: 
Chairman: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable Duncan Hunter: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

The Honorable Daniel K. Akaka: 
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: 

[End of correspondence] 

Enclosure I: Timing and Purpose of DOD Deployment-Based Health 
Assessments: 

Table 1: DOD Deployment-Based Health Assessments: 

Name: Pre-deployment health assessment; 
Purpose and description: 
* To record general information about servicemembers' health to 
identify any health concerns that may need to be addressed prior to 
deployment and can be used for surveillance purposes; 
* A health care provider is to review the pre-deployment health 
assessment, which is completed by servicemembers. If the provider 
identifies any health concerns that may affect servicemembers' ability 
to deploy, the provider may refer servicemembers for a further 
evaluation; 
* Required by the National Defense Authorization Act for Fiscal Year 
1998.[A]; 
Timing: Within 60 days prior to deployment. 

Name: Post-deployment health assessment (PDHA); 
Purpose and description: 
* To identify and refer servicemembers with health concerns as a result 
of deployment; 
* A health care provider is to review the PDHA, which is completed by 
servicemembers and conduct an interview to discuss any deployment-
related health concerns, including mental health concerns, with 
servicemembers. If necessary, the provider may refer servicemembers for 
further evaluation; 
* Required by the National Defense Authorization Act for Fiscal Year 
1998.[A]; 
Timing: Within 30 days before or 30 days after return from deployment. 

Name: Post-deployment health reassessment (PDHRA); 
Purpose and description: 
* To focus on servicemembers' health concerns that emerge over time 
after return from deployment; 
* A health care provider is to review the completed PDHRA, which is 
completed by servicemembers, and if necessary conduct an interview to 
discuss any deployment-related health concerns, including mental health 
concerns, with servicemembers. If necessary, the provider may refer 
servicemembers for further evaluation; 
* Initiated by DOD in 2005; 
Timing: Within 90 to 180 days after return from deployment. 

Source: DOD. 

[A] National Defense Authorization Act for Fiscal Year 1998, Pub. L. 
No. 105-85,  765(a)(1), 111 Stat. 1629, 1826 (1997) (codified as 
amended at 10 U.S.C.  1074f). 

[End of table] 

Enclosure II: Sample Post-Deployment Health Reassessment Form: 

This form must be completed electronically. Handwritten forms will not 
be accepted. 

Post-Deployment Health Re-Assessment (PDHRA): 

Privacy Act Statement 

Authority: 10 U.S.C. 136. 1074f. 3013, 5013. 8013 and E.O. 9337. 

Principal Purpose(S): To assess your state of health after deployment 
in support of military operations and to assist military healthcare 
providers in identifying and providing present and future medical care 
you may need. The information you provide may result in a referral for 
additional healthcare that may include medical, dental or behavioral 
healthcare or diverse community support services. 

Routine Use(S): In addition to those disclosures generally permitted 
under 5 U.S.C. 552a(b) of the Privacy Act, to other Federal and State 
agencies and civilian healthcare providers, as necessary, in order to 
provide necessary medical care and treatment. 

Disclosure: Voluntary. if not provided, healthcare Will Be furnished, 
but comprehensive care may not be possible. 

Instructions: Please read each question completely and carefully before 
entering your response or marking your selection. You Are Encouraged To 
Answer Each Question. Withholding or providing inaccurate information 
may impair a healthcare provider's ability to identify health problems 
and refer you to appropriate sources for additional evaluation or 
treatment. If you do not understand a question, please ask for help. 
Please respond based on your most recent deployment. 

Demographics: 

Last Name: 
First Name: 
Middle Initial: 
Social Security Number: 
Date of Birth: 
Today's Date: 
Date arrived theater: 
Date departed theater: 

Gender:	
Male: 
Female: 

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

Service Branch:	
Air Force: 
Army: 
Navy: 
Marine Corps: 
Coast Guard: 
Civilian Employee: 
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: 
O1: 
O2: 
O3: 
O4: 
O5: 
O6: 
O7: 
O8: 
O9: 
O10: 
W1: 
W2: 
W3: 
W4: 
W5: 
Other: 

Location of Operation: To what areas were you mainly deployed (land-
based operations more than 30 days)? Please mark all that apply, 
including the number of months spent at each location. 
Country 1: Months: 
Country 2: Months: 
Country 3: Months: 
Country 4: Months: 
Country 5: Months: 

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

Current Contact Information: 
Phone: 
Cell: 
DSN: 
Email: 
Address: 			
			
Total Deployments in Past 5 Years: 1, 2, 3, 4, 5 or more; 
0IF: 
OEF: 
Other: 

Current Unit of Assignment: 
Current Assignment Location: 

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

DD Form 2900, Jan 2008: 
Previous Edition is Obsolete: 

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. During the past 4 weeks, how difficult have physical health problems 
(illness or injury) made it for you to do your work or other regular 
daily activities? 
Not difficult at all: 
Somewhat difficult: 
Very difficult: 
Extremely difficult: 

4. During the past 4 weeks, how difficult have emotional problems (such 
as feeling depressed or anxious) 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: 

5. 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: 
6 or more: 

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

7. During your deployment, were you wounded, injured, assaulted or 
otherwise physically hurt? 
Yes: 
No: If no, skip to Question 8. 

7a. If Yes, are you still having problems related to this wound, 
assault, or injury? 
Yes: 
No: 
Unsure: 

8. In addition to wounds or injuries you listed in question 7, do you 
currently have a health concern or condition that you feel is related 
to your deployment? 
Yes: 
No: 
Unsure: 
If No, skip to Question 9. 

8a. If YES. please mark the item(s) that best describe your deployment-
related condition or concern: 
Fever: 
Cough lasting more than 3 weeks: 
Trouble breathing: 
Bad headaches: 
Generally feeling weak: 
Muscle aches: 
Swollen, stiff or painful joints: 
Back pain: 
Numbness or tingling in hands or feet: 
Trouble hearing: 
Ringing in the ears: 
Watery, red eyes: 
Dimming of vision, like the lights were going out:
Chest pain or pressure: 
Dizzy, light headed, passed out: 
Diarrhea, vomiting, or frequent indigestion/heartburn: 
Problems sleeping or still feeling tired after sleeping: 
Trouble concentrating, easily distracted: 
Forgetful or trouble remembering things: 
Hard to make up your mind or make decisions: 
Increased irritability: 
Taking more asks such as driving faster: 
Skin diseases of rashes: 
Other (please list): 

9a. During this deployment, did	you experience any of the following	
events?	(Mark all that apply] 

(1) Blast or explosion (IED, RPC, land mine, grenade: 
Yes: 
No: 
	
(2) Vehicular accident/crash ,any vehicle, including aircraft): 
Yes: 
No: 
		
(3) Fragment wound or bullet wound above your shoulders: 
Yes: 
No: 

(4) Fall: 
Yes: 
No: 

(5) Other event for example, a sports injury to your head); Describe: 

9b. Did any of the following happen to you, or were you told happened 
to you, immediately after any of the events you just noted in question 
9a? (Mark all that apply): 

(1) Lost consciousness or got "knocked out:" 
Yes: 
No: 

2) Felt dazed, confused, or "saw stars:" 
Yes: 
No: 

(3) Didn't remember the event: 
Yes: 
No: 

(4) Had a concussion: 
Yes: 
No: 

(5) Had a head injury: 
Yes: 
No: 

9c. Did any of the following problems begin or get worse after the 
events you noted in question 9a.? (Mark all that apply): 

Memory problems or lapses: 
Yes: 
No: 

Balance problems or dizziness: 
Yes: 
No: 

Ringing in the ears: 
Yes: 
No: 

Sensitivity to bright lights: 
Yes: 
No: 

Irritability: 
Yes: 
No: 

Headaches: 
Yes: 
No: 

Sleep problems: 
Yes: 
No: 

9d. In the past week, have you had any of the symptoms you indicated
in 9c? (Mark all that apply): 
Memory problems or lapses: 
Yes: 
No: 

Balance problems or dizziness: 
Yes: 
No: 

Ringing in the ears: 
Yes: 
No: 

Sensitivity to bright lights: 
Yes: 
No: 

Irritability: 
Yes: 
No: 

Headaches: 
Yes: 
No: 

Sleep problems: 
Yes: 
No: 

10. 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 11. 
Yes: 
No: 

10a. If yes, please mark the item(s) that best describe your concern: 
Animal bites: 
Animal bodies (dead): 
Chlorine gas: 
Depleted uranium (If yes, explain): 
Excessive vibration: 
Fog oils (smoke screen): 
Garbage: 
Human blood, body fluids, body parts, or dead bodies: 
Industrial pollution: 
Insect bites: 
Ionizing radiation: 
JP8 or other fuels: 
Lasers: 
Loud noises: 
Paints: 
Pesticides: 
Radar/Microwaves: 
Sand/dust: 
Smoke from burning trash or feces: 
Smoke from oil fire: 
Solvents: 
Tent heater smoke: 
Vehicle Or truck exhaust fumes: 
Other exposures to toxic chemicals or materials. such as ammonia, 	
nitric acid, etc. (If yes, explain): 
		
11. Since return from your deployment, have you had serious conflicts 
with your spouse, family members, close friends, or at work that 
continue to cause worry or concern? 
Yes: 
No: 
Unsure: 

12. Have you ever had any experience that was so frightening, horrible, 
or upsetting that, in the past month, you: 
a. Have had 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: 

13a. In the past month, Did you use alcohol more than you meant to? 
Yes: 
No: 

13b. In the Past Month, have you felt that you wanted to or needed to 
cut down on your drinking? 
Yes: 
No: 

13c. How often do you have a drink containing alcohol? 
Never: 
Monthly or less: 
2 to 4 times a month: 
2 to 3 times a week: 
4 or more times a week: 

13d. How many drinks containing alcohol do you have on a typical day 
when you are dunking? 
1 or 2: 
3 or 4:	
5 or 6: 
7 to 9:	
10 or more: 

13e. How often do you have six or more drinks on one occasion? 
Never: 
Less than monthly: 
Monthly: 
Weekly: 
Daily: 

14. Over the past month, have you been bothered by the following 
problems?	 

Little interest or pleasure in doing things: 
Not at all: 
Few or several days: 
More than half the days: 
Nearly every day: 

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

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

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

17. Are you currently interested in receiving assistance for a family 
or relationship concern? 
Yes: 
No: 

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

Health Care Provider Only: 

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. Conduct risk assessment. 

a. Over the past month, have you been bothered by thoughts that you 
would be better off dead or 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 member reports positive or unsure response to 2a. or 2b,, 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: 

b. Outcome of assessment: 
Immediate referral: 	
Routine follow-up: 
Referral not indicated: 
	
4. Alcohol screening result: 
No evidence of alcohol-related problem; 
Potential alcohol problem (positive response to either question 13a or 
13b, and/or Audit-C (questions 13c.-e.) score of 4 or more for men or 3 
or more for women): 
Refer to PCM for evaluation: 
Yes: 
No: 

5. Traumatic Brain Injury (TBI) risk assessment: 
No evidence of risk based on responses to questions 9.a.-d: 
Potential TBI with persistent symptoms, based on responses to question 
9d. 
Refer for additional evaluation: 
Yes: 
No: 

6. 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): 

7. Identified Concerns: 

Physical symptoms: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Exposure Symptoms: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Depression symptoms: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

PTSD symptoms: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Anger/Aggression: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Suicidal Ideation: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Social/Family Conflict: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Alcohol Use: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

Other: 
Minor concern: 
Major concern: 
Already under care (yes/no): 

8. Referral information: 

a. Primary Care, Family Practice: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

b. Behavioral Health in Primary Care: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

c. Mental Health Specialty Care: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

d. Other specialty care: 
Audiology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Cardiology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Dentistry: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Dermatology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

ENT: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

GI: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Internal Medicine: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Neurology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

OB/GYN: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Ophthalmology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Optometry: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Orthopedics: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Pulmonology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

Urology: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

e. Case Manager, Care Manager: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

f. Substance Abuse Program: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

g. Health Promotion, Health Education: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

h. Chaplain: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 
	
i. Family Support Community Service: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

j. Military OneSource: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 

k. Other: 
Within 24 hours: 
Within 7 days: 
Within 30 days: 
				
l. No referral made: 

9. Comments: 

I certify that this review process has been completed. 

10. Provider's signature and stamp: 

Ancillary Staff/Administrative Section: 

11. 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: 
LOD: 	
Other: 

12. Referral was 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 section] 

Enclosure III: Comments from the Department of Defense: 

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

Mr. Randall B. Williamson: 
Acting Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, N.W. 
Washington, DC 20548: 

Dear Mr. Williamson: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) draft report, GAO-08-1025R, "Defense Health 
Care: Oversight of Military Services' Post-Deployment Health 
Reassessment Completion Rates is Limited," dated July 31, 2008 (GAO 
Code 290686). 

Thank you for the opportunity to review and provide comments. Overall, 
we concur with the draft report's findings and conclusions. Although 
there were no formal recommendations, there are several items in the 
report that we would like to address. 

A recurrent theme in this report is that DoD's quality assurance (QA) 
program is unable to accurately assess whether post-deployment health 
reassessments (PDHRAs) are completed and fails to adequately "oversee" 
the PDHRA program. Possibly this is a matter of semantics, but some 
dictionaries define oversight to include supervision or management, 
which would be beyond the scope of a QA program. The actual management 
and execution of the program is the responsibility of the commanders 
and the Military Health System. 

This GAO report suggests that PDHRA compliance cannot be accurately 
assessed without the military Services providing consistent and 
complete information to the Deployment Health QA program office. The 
real key is in the military Services providing complete and accurate 
information to the enterprise-wide systems of record that have been 
identified, such as the Defense Manpower Data Center (DMDC) and the 
Defense Medical Surveillance System (DMSS). From these systems, 
accurate compliance calculations will be available at any time, to both 
the Services and the QA office, eliminating redundant reporting. To 
this end, DoD has been working hard since November 2007 to develop high 
quality data feeds from the Services to DMDC and DMSS. Given the past 
criticisms DoD has received for accepting Service data at face value, 
this seems the only way to ensure accurate compliance monitoring. 

In addition, DoD does not conduct site visits as a core mechanism for 
validating quarterly Service QA input. Site visits allow us to get a 
feel for the operational realities of force health protection and to 
provide staff assistance in a nonthreatening fashion. Such visits 
cannot possibly provide the volume of data necessary to validate the 
information contained in Service and DoD databases; hence, our emphasis 
is on analyzing and improving those systems, as mentioned above. 

Regarding "... inconsistencies within a Service and among the Services, 
..." you highlight the differences between the Army's 2007 quarterly 
reports and differences between the Army and the other Services. Given 
the non-homogenous nature of combat operations among the Services 
(deployments of large versus small units versus individual augmentees, 
variable tour lengths, etc.), it is unlikely the reports would ever 
look the same over time. 

The report also emphasizes the failure of DoD to "... work with Armed 
Forces Health Surveillance Center (AFHSC) to specify reporting 
requirements ..." The situation has changed considerably since the GAO-
07-831 report. The AFHSC was not officially established until February 
2008. In the meantime, the AFHSC staff has developed a detailed 
compliance assessment methodology using DMSS and other DoD-level data 
sources, as you mention. Consequently, there hasn't been any need to 
modify the other routine AFHSC reports that were designed to match 
those produced for the Department of Defense Forms 2796, per customer 
needs. 

Finally, there is one important misstatement (enclosure 1) that needs 
correction. In the pre-deployment health assessment section, you 
mention that this assessment is performed for "surveillance purposes." 
This is incorrect. All three of the deployment-health assessments were 
designed as clinical encounters with the primary goal of maintaining or 
improving the Service member's health. The self-reporting tools (DD 
Forms 2795, 2796, and 2900) were designed as clinical support tools. We 
simply do our best to leverage the information on the forms for 
surveillance purposes. 

Thank you for the opportunity to review and comment on the draft 
report. My points of contact for additional information are Colonel 
Kenneth Cox, who may be reached at Kenneth.Cox1@ha.osd.mil or (703) 578-
8524, and Mr. Gunther Zimmerman, who may be reached at 
Gunther.Zimmerman@tma.osd.mil or (703) 681-4360. 

Sincerely, 

Signed by: 
S. Ward Casscells, MD: 

Enclosure: As stated 

[End of section] 

GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov: 

Acknowledgments: 

In addition to the contact named above, Mary Ann Curran, Assistant 
Director; Martha Fisher; Drew Long; Jasleen Modi; Lisa Motley; and 
Samantha Poppe made key contributions to this report. 

[End of section] 

Footnotes: 

[1] P. 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," The New England Journal of Medicine, 351, (2004.) 

[2] C.S. Milliken, J.L. Auchterlonie, C.W. Hoge, "Longitudinal 
Assessment of Mental Health Problems Among Active and Reserve Component 
Soldiers Returning From the Iraq War," Journal of the American Medical 
Association, 298(18) (2007):2141-2148. 

[3] 10 U.S.C.  1073b(a). 

[4] GAO, Defense Health Care: Comprehensive Oversight Framework Needed 
to Help Ensure Effective Implementation of a Deployment Health Quality 
Assurance Program, [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
831] (Washington, D.C.: June 22, 2007). 

[5] GAO, Military Personnel: Top Management Attention is Needed to 
Address Long-standing Problems with Determining Medical and Physical 
Fitness of the Reserve Force, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-06-105] (Washington, D.C.: Oct. 27, 2006); GAO, DOD 
Civilian Personnel: Greater Oversight and Quality Assurance Needed to 
Ensure Force Health Protection and Surveillance for Those Deployed, 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-06-1085] (Washington, 
D.C.: Sept. 29, 2006); GAO, Defense Health Care: Force Health 
Protection and Surveillance Policy Compliance Was Mixed, but Appears 
Better for Recent Deployments, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-120] (Washington, D.C.: Nov. 12, 2004); and GAO, 
Defense Health Care: Quality Assurance Process Needed to Improve Force 
Health Protection and Surveillance, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-03-1041] (Washington, D.C.: Sept. 19, 2003). 

[6] S. Rep. No. 110-77, at 360 (2007). 

[7] For purposes of this report, "servicemembers" include active duty 
and Reserve components. 

[8] DOD's policy delegates the responsibility for executing the quality 
assurance program to the Deputy Assistant Secretary of Defense for 
Force Health Protection and Readiness. In this report, we refer to this 
quality assurance program as "DOD's quality assurance program." 

[9] AFHSC is a DOD agency that performs comprehensive medical 
surveillance and reporting on rates of diseases and injuries among 
servicemembers. AFHSC operates the Defense Medical Surveillance System 
(DMSS), which contains data on diseases and medical events and 
longitudinal data on personnel and deployments, including deployment 
health assessments. Each of the military services is required to 
electronically submit completed PDHRAs to DMSS. 

[10] Assistant Secretary of Defense for Health Affairs Memorandum, 
"Post-Deployment Health Reassessment," (Mar. 10, 2005), and Department 
of Defense Instruction 6490.03, Section E4.A3.2.12, "Deployment 
Health," (Aug. 11, 2006). 

[11] Servicemembers who are deployed overseas for more than 30 
continuous days to locations without permanent military treatment 
facilities are required to complete PDHRA. It is the commander's 
decision whether servicemembers who do not meet the criteria complete 
these health assessments. 

[12] The quality assurance program was required by the National Defense 
Authorization Act for Fiscal Year 1998, Pub. L. No. 105-85,  
765(a)(1), 111 Stat. 1629, 1826 (1997) (codified as amended at 10 
U.S.C.  1074f(d)). 

[13] DOD's policy and implementing guidance for the program is 
contained in a 2004 policy memorandum, Assistant Secretary of Defense 
for Health Affairs, "Policy for Department of Defense Deployment Health 
Quality Assurance Program," (Jan. 9, 2004). DOD subsequently issued 
additional guidance for the quality assurance program in 2007. DOD 
Instruction 6200.05, "Force Health Protection (FHP) Quality Assurance 
(QA) Program," (Feb. 16, 2007). 

[14] According to DOD's quality assurance program manager, other DOD 
and military services staff provide analytical assistance to the 
quality assurance program as needed. 

[15] [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-831]. 

[16] Site visits are planned, coordinated, and conducted jointly by 
staff members from DOD's quality assurance program and the services' 
medical department. 

[End of section] 

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