VA Preparedness Survey

OMB No. 2900-XXXX

Estimated Burden: 10 Minutes

OMB Expiration Date: XX/XX/XXXX

DEPARTMENT OF VETERANS AFFAIRS Veterans Health Administration Washington DC 20420

Date: [INSERT CURRENT DATE]

Dear: [INSERT FIRST AND LAST NAME]:

I am writing to ask for your help with a short but important survey that will give you the opportunity to help your fellow Veterans. Your opinion will help improve communication about where it is safe for Veterans to get care in the event of a natural disaster. This survey has been sent to you and other Veterans in the Northeastern U.S.

You were selected to participate in this study because our records show you visited a VA hospital or clinic in the past two years. Even if you do not frequently get care from the VA, we are interested in your opinions. The survey will ask you about your experiences with natural disasters, your preferences for communication with the VA, and some general questions about your health. I know your time is valuable, but I hope you will take 10 minutes to participate in this survey.

Enclosed you will find $2.00 in cash as a token of our appreciation for your time. You can answer the survey on the internet by entering the following URL into the address bar of your internet browser:

URL

Once there, please enter XXXX as your online survey code.

Please note that participation in this study is voluntary and your decision will not affect any services you receive from VA or your eligibility for services in the future. Your answers will be kept confidential. No one will connect your name to any information that you provide. We will combine your answers with answers from other participating Veterans and show data only as totals and averages.

If you have any questions about the survey, or experience technical difficulties with the online survey and need assistance, please call 800-xxx-xxxx or email the study team at XXXX@altarum.org.

Your fellow Veterans need your help. Reply today!

Sincerely,

OMB Control Number: [insert number]

Expiration: [insert date]

Public Reporting Burden 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 10 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 effect 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 with the VA benefits processing system and for associated administrative 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.

Dr. Daniel J. Bochicchio
Director, VHA Office of Emergency Management