Home MethodsThe LiverVA NewsSurvey Results

Survey- Veterans/Active Military
& Dependents with Hepatitis C

This information will help us determine clusters with hepatitis C infected by the same transmission method. We will post the results as soon as we get them. We will not post your name or email address.  If you changed or re-enlisted please enter a separate record for each enlistment.

When filling out this form, do not hit the enter key until you are finished. Use the tab key  (top left of keyboard)  to move between the fields. The enter key will submit the form before you are finished. If that does happen, use the back button on the browser and continue where you left off. Use the submit button or enter key when the form is completed

Please enter:
E-mail 
Name
First   Last
Check this box if updating  information all ready
submitted to the Database 

Please select:  Branch of Service   

Do you have Hepatitis C? Yes No
If Yes, Please enter your Genotype (1, 1a, 1b, 2a, 2b, 3a etc)
Genotype is the genetic code of what type of Hepatitis C you have. There are several
different types. If you do not know, please find out and update your info.
 Genotype 

Do you or did you have Hepatitis B? Yes No

 

VA Claim

Is your claim completed? (No longer in the VA system ) Yes No

     If Yes, How long did the whole process take from the day you filed your claim?
     Less than Years.

Did you appeal the percentage? Yes No

Transmission Methods
 Did you receive an immune globulin shot?  
This shot was given to soldiers exposed to outbreaks of Hepatitis A & B. Immune globulin is also used in the smallpox vaccinia shot given in case of reaction to the smallpox vaccine.

Check any and all methods you may have been
exposed to the hepatitis C virus during military service.  

Jet "Air Gun" Injections Used Razors (dry shaving) Medical/ Dental (no  gloves)
Reused Syringes & Vials Barber Electric Razors Medical Surgery
Finger pricks with Lancets   Barber Straight Edge     Dental Surgery
Contaminated Vaccine/ Immune Serum Globulin (ISG)  Share Rags/cleaned bloody equipment Share Nail Clippers, files, or personal grooming items
Blood Transfusions Tattoos   Used Tooth Brush  
Donate Blood   Exposed to Blood/body fluid Had an STD
Tissue/Bone Transplant GYN Exam Endoscope Exam
Kidney/Blood Dialyses Ear Nose & Throat Exam Colonoscopy Exam  


Military Service Record

Boot Camp & Military Service Information
  Boot Camp Name/  Type name here if not
listed above		   
 
(Command, Platoon, unit, area)
City
State   
Month/Year entered boot camp     
         

2 Duty Station

 Duty Stations  Name/NickName
(Command, Platoon, unit, area)
City
State    Other 
Month/ Year assigned       
Country

3 Duty Station
  Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State    Other
Month/Year assigned     
Country

4 Duty Station

 Duty Stations Name/ NickName
(Command, Platoon, unit, area)
City
State   Other 
Month/Year assigned     
Country
 

 5 Duty Station
Duty Stations Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned    
Country

6 Duty Station
 Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State Other 
Month/Year assigned    
Country

7 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other 
Month/Year assigned    
Country

8 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned        
Country

 9 Duty Station
  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned    
Country
10 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned        
Country
11 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned       
Country
12 Duty Station
Duty Stations  Name/ NickName
(Command, Platoon, unit, area)
City
State   Other
Month/Year assigned        
Country