U. S. Armed forces veteran survey

State of Wisconsin Department of Administration Division of Personnel Management DOA-15100 (C06/2015) s. 230.04 (10) (c), Wis. Stats. Previously OSER-DAA-16

VETERANS NEW HIRE INFORMATION
SECTION A: PLEASE COMPLETE WHETHER YOU ARE A VETERAN OR NOT.
PLEASE PRINT CLEARLY

LAST NAME	FIRST NAME	LAST 4 DIGITS OF SSN
AGENCY NAME		AGENCY NUMBER
SECTION B: Indicate whether you are a veteran or are not a veteran. (See definition below.)  I am a veteran. Complete SECTION C if applicable. Please sign, date and return form to your payroll office.  I am not a veteran. Note: Spouses of disabled or deceased veterans may need to complete SECTION C. Please sign, date and return form to your payroll office. “Veteran” means any of the following: A person who served on active duty under honorable conditions in the U.S. armed forces and who was entitled to receive any of the following: The armed forces expeditionary medal established by executive order 10877 on December 4, 1961. The Vietnam service medal established by executive order 11231 on Jul 8, 1965. The navy expeditionary medal. The marine corps expeditionary medal. A person who served on active duty under honorable conditions in the U.S. armed forces in a crisis zone, as defined in s. 45.01(11), Wis. Stats. A person who served on active duty under honorable conditions in the U.S. armed forces for at least one day during a war period, as defined in s. 45.01 (13), Wis. Stats., or under section 1 of executive order 10957 dated August 10, 1961. A person who served on active duty under honorable conditions in the U.S. armed forces for 2 continuous years or more or the full period of the person’s initial service obligation, whichever is less. A person discharged from the U.S. armed forces for reasons of hardship or a service-connected disability or a person released due to a reduction in the U.S. armed forces prior to the completion of the required period of service shall also be considered a “veteran” regardless of the actual time served. Section 230.03(14), Wis. Stats. SECTION C: Disabled Veterans and Spouses of Disabled or Deceased Veterans. Check only one box.

A.  Veteran with less than 30% service-connected disability.

B.  Veteran with at least 30% but less than 70% service-connected disability.

C.  Veteran with a 70% or greater service-connected disability.

D.  Spouse of a disabled veteran whose service-connected disability is at least 70%.

E.  Disabled spouse of a disabled veteran whose service-connected disability is at least 70%.

F.  Severely disabled spouse of a disabled veteran whose service-connected disability is at least 70%.

G.  Unremarried spouse of a veteran killed in action or a veteran who died of a service-connected disability.

H.  Disabled unremarried spouse of a veteran killed in action or a veteran who died of a service-connected disability.

I.  Severely disabled unremarried spouse of a veteran killed in action or a veteran who died of a service-connected disability.

SIGNATURE: __________________________________ DATE SIGNED: ___________________