Va 2

VETERAN
FEEDBACK
SURVEY
OMB Control Number: 2900-XXXX
Public Reporting Burden and Privacy Act Statement
VA may not conduct, sponsor, or require the respondent to respond to this collection of information unless it displays a
valid OMB Control Number. All responses to this collection are voluntary. Public reporting burden for this collection of
information is estimated to average 15 minutes per response, including the time necessary for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Failure to furnish the requested information will have no adverse affect on any VA benefits to
which you may be entitled.
The information you supply will be confidential and protected by the Privacy Act of 1974 (5 U.S.C. 522a) and the VA's
confidentiality statute (38 U.S.C. 5701) as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b). Disclosure of
information involves releases of statistical data and other non-identifying data for the improvement of services within the
VA benefits processing system and for associated purposes. If you have comments regarding this burden estimate or
any aspects of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.

ABOUT YOU
1.

What is your highest level of education completed?
Some high school
High school graduate or GED certificate
Some college
College graduate
Post-graduate study or degree

2.

Are you... (mark all that apply)
American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Asian

White

Black/African American

Prefer not to answer

Other
3.

Latino/Hispanic
Yes
No

4.

What is your current marital status?
Married

Widowed

Separated

Not married

Divorced

Prefer not to answer

5.

In which zip code
do you currently
reside?

6.

How far do you live from the nearest military installation?
Less than 10 minutes

30 - 59 minutes

10 - 19 minutes

60 minutes or more

20 - 29 minutes

7.

Are you aware of the VA Home Loan Program?
Yes
No

8.

Do you now, or have you ever had a VA loan?
Yes
No
Not sure

Did you apply for VA disability compensation in the last five (5) years?
Yes - continue to question # 9
No - skip to question # 27

9.

How would you classify your living
situation at the time of application for
disability benefits?

11.

Own a home outright (no mortgage)

At time of application for disability
benefits, did you experience any of the
following? (Mark all that apply.)
Water leaking in from
roof

Water leaking in from
window(s)

Renting

Water leaking in from
door(s)

Water leaking in from
basement

Temporarily staying with friends/family with no
rent

Water leaking in from
walls/floors

Water leaking inside
the unit from plumbing
pipes or fixtures

Holes in the floors

Holes or cracks in the
walls

Holes or cracks in the
ceilings

Pest infestation(s)
[i.e., rodents or
insects]

Have a mortgage on a home

Live in base housing
Other
10.

At time of application for disability
benefits, did the inside of your
residence LACK any of the following?
(Mark all that apply.)
Hot running water

Cold running water

Flush toilet

Bathtub

Shower

Functional heating
system

Functional heating
source

Working electricity

Functional outlets

Functional fuses and
circuit breaker

Did not experience
any of the above

12.

Did not lack any of the
above
13.

At time of application for disability
benefits, what was the total number of
rooms in your home?(Do NOT count
bathrooms,porches, balconies, foyers,
halls, half-rooms or unfinished
basements.)
1

2

3

4

5

6

7

8

9 or more

At time of application for disability
benefits, how many people lived in your
home (include yourself in this number)?
1

2

3

4

5

6

7

8

9

10 or more

14.

If you receive disability compensation from VA, how did the time taken to process your
claim impact the quality of your living situation?
Not much impact (continued same living situation)
Some impact (had difficulty in maintaining living situation)
Significant impact (had to seek other living situation)
Severe impact (forced to move to other living situation)
Do not receive disability compensation
Filed and waiting for a decision on my disability compensation status/rating

15.

16.

How many times did you move between the time you applied for benefits and the point
at which you received a decision on your claim for disability benefits?
1

3

5

7

9 or more

2

4

6

8

None - never
moved

During your wait period, what was your level of satisfaction with your living condition?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

While waiting for a decision from VA about your claim for disability compensation...
Yes
17.

Were you ever behind in your
mortgage payments by 2 months
or more?

18.

Were you ever behind in your
rental payments by 2 months or
more?

19.

Was your home ever referred for
foreclosure?

20.

Were you ever threatened with
eviction from a rental property?

No

Not sure

Not applicable

21.

If you are waiting on a decision from VA
about a claim for disability
compensation, how is the time to
process your claim impacting the
quality of your living situation? (select
only one)

24.

Not much impact (continued same living
situation)
Some impact (had difficulty in maintaining living
situation)
Significant impact (had to seek other living
situation)
Severe impact (forced to move to other living
situation)
Not waiting on a claim decision from VA
22.

If you are waiting on a decision from VA
about a claim for disability
compensation, how many times have
you moved since the time you applied
for benefits?
0

1

2

3

4

5

6

7

8

23.

25.

26.

While waiting for a decision on your
claim, did the inside of your residence
LACK any of the following? (Mark all
that apply.)
Hot running water

Cold running water

Flush toilet

Bathtub

Shower

Functional heating
system

Functional heating
source

Working electricity

Functional outlets

Functional fuses and
circuit breaker

Water leaking in from
roof

Water leaking in from
window(s)

Water leaking in from
door(s)

Water leaking in from
basement

Water leaking in from
walls/floors

Water leaking inside
the unit from plumbing
pipes or fixtures

Holes in the floors

Holes or cracks in the
walls

Holes or cracks in the
ceilings

Pest infestation(s)
[i.e., rodents or
insects]

Did not experience
any of the above

9 or more

Not waiting on a claim
decision from VA

While waiting for a decision on your
claim, did you experience any of the
following? (Mark all that apply.)

While waiting for a decision on your
claim, what was the total number of
rooms in your home? (Do NOT count
bathrooms,porches, balconies, foyers,
halls, half-rooms or unfinished
basements.)
1

2

3

4

5

6

7

8

9 or more

While waiting for a decision on your
claim, how many people lived in your
home (include yourself in this number)?
1

2

3

4

5

6

7

8

9

10 or more

Did not lack any of the
above

27.

What is your current living situation?
Own a home outright (no mortgage)
Have a mortgage on a home
Renting
Temporarily staying with friends/family with no rent
Live in base housing
Other

28.

What is your level of satisfaction with your current living situation?
Very satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied

Comments
Please feel free to comment in the space below about any issues you would like to address. (Max. 500
characters)