0925c Media and News Release Questionnaire, National Veterans

ATHLETE NUMBER-OFFICE USE ONLY

OMB Number:
Respondent Burden: 20 minutes

MEDIA AND NEWS RELEASE
QUESTIONNAIRE
NATIONAL VETERANS WHEELCHAIR GAMES
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

All athletes must complete questions 1-15, whether or not you wish to have a news release. If you would like a news release posted on
the Games website about your participation this year, you must fill out this form completely. Our Hometown News program promotes
publicity about the National Veterans Wheelchair Games by posting an individual news release for every veteran who wants one on the
website during the week of the Games. The releases may be found on the Games' website, www.wheelchairgames.va.gov. In order to
prepare your news release, we must have all needed information in advance. We cannot gather this information during the Games. If
you have any questions, please call VA Public Affairs at (734) 845-3377.
NAME (Last, First, MI)

TEAM NAME (If applicable)

DATE OF BIRTH

E-MAIL ADDRESS

1. PLEASE CONFIRM YOUR BRANCH OF SERVICE
ARMY

AIR FORCE

MARINE CORPS

COAST GUARD

NAVY

NATIONAL GUARD

BRITISH MILITARY

OTHER (Please specify)
2. IF YOU ARE A PEACETIME VETERAN, WHERE AND WHEN DID YOU SERVE?
3. DID YOU SERVE IN COMBAT IN ANY OF THE FOLLOWING CONFLICTS?
KOREA

WWII

THE GULF WAR

VIETNAM

AFGHANISTAN

IRAQ

OTHER (Please specify)
4. IS YOUR INJURY OR ILLNESS, REQUIRING THE USE OF A WHEELCHAIR, COMBAT RELATED? (Resulting from actual service in combat)
YES

NO

5. WHAT DID YOU DO IN THE SERVICE?
6. HOW WERE YOU INJURED?
7. WERE YOU EVER HELD AS A POW? (If yes, where)

YES

8. ARE YOU A VIETNAM ERA (NONCOMBAT) VETERAN?

NO
YES

NO

9. UNDER WHICH GENERAL CONDITION DOES YOUR DIAGNOSIS FALL?
AMPUTEE

PARAPLEGIC

STROKE

QUADRIPLEGIC

RIGHT LEG

AK

OR

BK

OTHER NEUROLOGICAL INJURY OR DISEASE

MULTIPLE SCLEROSIS

LEFT LEG

AK

OR

BK

HIP/KNEE REPLACEMENT

BRAIN INJURY

OTHER AMPUTATION

SEVERE ARTHRITIS

OTHER DIAGNOSIS (Describe in simple language, not medical terms)
10. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
AMVETS

MOPH

PVA

DAV

VFW

AMERICAN LEGION

OTHER

11. WHAT IS YOUR PRIMARY VA MEDICAL CENTER (City, State)

12. HOW MANY PAST YEARS HAVE YOU PARTICIPATED IN THE
NATIONAL VETERANS WHEELCHAIR GAMES (NVWG)?

13. DO YOU WANT US TO PREPARE A NEWS RELEASE ABOUT YOUR
PARTICIPATION IN THIS EVENT?
YES

VA FORM
APR 2010

0925c

NO

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14. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 13, PLEASE PROVIDE THE FOLLOWING INFORMATION.
REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION: I REQUEST AND AUTHORIZE
THE DEPARTMENT OF VETERANS AFFAIRS TO RELEASE THE MEDICAL INFORMATION CONTAINED ON THIS FORM FOR VA MEDIA
PURPOSES.
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED ON THE GAMES' WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
15. PLEASE NOTE: WHETHER OR NOT YOU WANT A NEWS RELEASE, ALL EVENT RESULTS WILL BE POSTED ON THE GAMES' WEBSITE BY
PARTICIPANT NAME UNLESS YOU CHECK THE "NO" BOX HERE.
NO (Results will not be posted; sign at bottom of this page)
16. YOUR QUOTE FOR THE NEW RELEASE: (This is mandatory) (All we need are a few thoughts from you telling us such things as how you feel about the
Games, what sports competition has done for your life, how many times you've competed, what you have looked forward to the most, your past experience in sports, what
you hope to achieve, favorite sports, etc. Just give us a few ideas, and we'll take it from there.)

SIGNATURE (You must sign here so we can comply with your wishes)

VA FORM 0925c, APR 2010, page 2

DATE SIGNED