0927d Media and News Release Questionnaire, National Veterans

OMB Number:
Respondent Burden: 20 minutes

MEDIA AND NEWS RELEASE
QUESTIONNAIRE
NATIONAL VETERANS TEE TOURNAMENT
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”.
Providing the requested information is voluntary.
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 1-11, whether or not you wish to have a news release. If you would like a news release posted on
the Tournament's website about your participation this year, you must fill out this form completely. Our Hometown News program
promotes publicity about the event by posting an individual news release for every Veteran who wants one on the Tournament's website
during the week of the event. The releases may be found on the Tournament's website, www.tee.va.gov. In order to prepare your news
release, we must have all needed information in advance. We cannot gather this information during the Tournament. If you have any
questions, please call VA Public Affairs at (734) 845-3706.
NAME (Last, First, MI)
TELEPHONE NUMBER (Include area code)
DATE OF BIRTH
CELL PHONE NUMBER (Include area code)

E-MAIL ADDRESS
1. PLEASE CONFIRM YOUR BRANCH OF SERVICE
ARMY
MARINE CORPS
AIR FORCE
COAST GUARD

NAVY

NATIONAL GUARD

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
THE GULF WAR
WWII
VIETNAM
IRAQ
AFGHANISTAN
OTHER (Please specify)
YES

4. WERE YOU EVER HELD AS A POW? (If yes, where)

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

NO

YES

NO

6. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
AMERICAN LEGION

AMVETS

MOPH

BVA

PVA

DAV

VFW

OTHER

7. WHAT IS YOUR PRIMARY DISABILITY/DIAGNOSIS?
VISUAL IMPAIRMENT
LEGALLY BLIND
TOTALLY BLIND
SPINAL CORD INJURY (SCI) - LEVEL

COMPLETE

INCOMPLETE

PARAPLEGIC
QUADRIPLEGIC
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
CVA WITH RESIDUAL
AMPUTEE

RIGHT LEG
LEFT LEG

AK OR
AK OR

BK

RIGHT ARM

BK

LEFT ARM

AE OR
AE OR

BE
BE

OTHER
VA FORM
APR 2010

0927d

Adobe LiveCycle Designer

8. HOW MANY PAST YEARS HAVE YOU
PARTICIPATED IN THE NATIONAL VETERANS TEE
TOURNAMENT?

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

NO

10. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 9, 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. (If you checked this block, please check
one of the boxes below.)
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED
ON THE EVENTS' WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
11. PLEASE NOTE: WHETHER OR NOT YOU WANT A NEWS RELEASE, TOURNAMENT RESULTS WILL BE
POSTED ON THE TOURNAMENT WEBSITE BY PARTICIPANT NAME UNLESS YOU CHECK THE "NO" BOX HERE.
NO (Results will not be posted; sign below)
12. 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 Tournament, what sports has done for your life, how many times you've attended, what you have
looked forward to the most, your past experience in golf or other 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 0927d, APR 2010, page 2

DATE SIGNED