10-0485 Group 2 Print Survey

25.

People have many types of health insurance and
sometimes more than one. Please tell me if you
have any of the following by marking Yes or No
for each item below.
Yes
No

32.

What is the highest grade or level of school that
you have completed?

Department of Veterans Affairs
Veterans Emergency Management Evaluation Center

8th grade or less

VA Preparedness Communications Survey

Some high school, but did not graduate

Care paid for or provided by VA
Employer based or private
insurance

High school graduate or GED
Your fellow Veterans need your help. Your response will shape the way VA
communicates with Veterans in the event of a natural disaster.

Some college or 2-year degree
4-year college graduate

Medicaid

OMB Control Number:
Expiration Date:

More than 4-year college degree

Medicare
Other, please specify:

33.

What is your current employment status?

1.

Employed for wages or salary
Self-employed
26.

Are you now, or have you ever been homeless?
Yes

27.

Yes

Unable to work or disabled

No

Not employed
28.
29.

Are you male or female?

Male

Female

34.

4.

$30,001 to $50,000

White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander

36.

American Indian or Alaska Native
Other

37.

What is you current marital status?
Currently married
Living as married

How many people, including yourself, live in
your household?
Did someone help you complete this survey?
Yes

No

How did that person help you? (Mark one or more)

Earthquake
Severe winter storm

No →Go to End

Severe heat wave
Other, please specify:

In the past 12 months, how many times did you
visit a VA hospital or clinic to get care for yourself?

8.

Television

4

Newspaper

5 to 9

Radio

10 or more times

Online

Please think of all the health care you receive both
from the VA and from somewhere else. How much
of your health care do you currently get from VA?
I get all of my health care from VA

Wrote down the answers I gave

I get some of my health care from VA

Answered the questions for me

6.

In general, where do you usually first hear about
natural disasters? (Mark one)

3

I get most of my health care from VA

Now think about the VA medical facility you go to
most frequently. If that VA facility was closed due to
a natural disaster, how easy would it be for you to
get care elsewhere?

Separated

Very easy

Never married

Somewhat easy
Neither easy nor hard

Thank you for completing this survey and helping your fellow Veterans.
Please return this survey today in the self-addressed envelope.

Fire

In the past 24 months, have you received any
health care services at a Veterans Affairs (VA)
hospital or clinic?

Read the questions to me

Help me in some other way, please specify:

Divorced

5.

→Go to End

Translated the questions into my language

Widowed

Flood

2

More than $100,000
35.

Tornado

No

1 time

$80,001 to $100,000

What is your race? (Mark one or more)

Which of the following natural disaster events have
you experienced in the past 20 years? Please
mark Yes or No for each item.
Yes
No

Never

$50,001 to $80,000

Don't know

31.

Which of the following categories best reflects your
total annual household income?

$10,001 to $30,000

No, not Hispanic, Spanish or Latino

No →Go to End

Are you currently a paid employee of the
Department of Veterans Affairs?
Yes →Go to End

3.

Less than $10,000

Yes, Hispanic, Spanish or Latino

30.

2.

Yes

Are you of Hispanic, Spanish or Latino origin or
descent?

7.

Hurricane

Retired
A Full-time caregiver, homemaker, student, or
volunteer

What is your age?

Are you now, or have you ever, served on active
duty or been called to active duty as a
Guard/Reservist?

Somewhat hard
Very hard

Family, friends or co-workers
9.

Where do you usually go to keep up to date on a
natural disaster in your area as it is happening?
(Mark one)
Television
Newspaper
Radio
Online
Family, friends or co-workers

10.

Do you currently have the following in case of a natural disaster? Please mark Yes or No for each item.
Yes
No

16.

To access the internet, which device do you use most often? (Mark one)
A computer

A battery powered or hand-cranked radio?

A tablet (e.g. iPad, Nexus 7, Samsung Galaxy Tab)

A generator in case of a power outage?

A smart phone (iPhone, Blackberry, Samsung Galaxy S4)

A plan for communicating in the event that phone service is disrupted?
A subscription to local emergency e-mail or text alerts?

17.

In the event of a natural disaster the VA may need to contact you about your health care, appointments, and
where it is safe to get care. The next several questions will ask you about how you stay in contact with the VA.

How helpful would you find each type of communication from the VA in the event of a natural disaster in your area?
Mark one per each row.
A little
Somewhat
Extremely
helpful
helpful
helpful
Not helpful
Very helpful
Do not use
E-mail notification

11.

In general, which of the following sources of information do you depend on most to stay informed about the status
of your health care appointments at a VA hospital or clinic? (Mark one)

Facebook updates
Twitter updates

A social worker

My HealtheVet notification
Other VA hospital or web page
updates

Administrative staff (i.e. front desk or nursing staff at the hospital or clinic)
Someone helping you (friends or family)
The hospital or clinic website........................................................................

→Go to Q13

My HealtheVet...............................................................................................

→Go to Q13

Thank you for sharing your experiences and opinions. The following are general questions about you and your
health.

Other, please specify:
18.

12.

How do you usually communicate with the information source you just mentioned about your health care
appointments? (Mark one)
In person

13.

Over the phone

Through e-mail

Online

In the event that a natural disaster occurs in your area, and you still have power, how helpful would you find the
following types of communication from the VA? Mark one per each row.
A little
Somewhat
Extremely
helpful
helpful
helpful
Not helpful
Very helpful
Do not use

19.

20.

Radio
Telephone
Text (SMS) message
How often do you go online for work or personal
use?
Never.......................
Rarely
At least once a month
At least once a week
Daily

→Go to Q18

15.

Without using any special equipment, how much
difficulty do you have using your fingers to grasp or
handle small objects?

Never

No difficulty

Rarely

Some difficulty

At least once a month

Much difficulty

At least once a week

Unable to do so

Do you currently take any prescription medication?
Yes

Newspaper

22.

Daily

Television

14.

How often do you communicate with others in your
social network such as friends, family, co-workers,
or members of an organization you belong to?

How often do you log-on to My HealtheVet?

23.

No

Would you say your eyesight, without glasses or
contact lenses if you wear them, is
Excellent

Do you use any of the following equipment
because of a condition other than a temporary
injury? Please mark Yes or No for each item.
Yes
No

Very good

Manually operated wheelchair?
Motorized wheelchair, cart, or
scooter?

Poor

Good
Fair

24.

How much difficulty do you have hearing without a
hearing aid or other listening devices?

Never

Crutches?

Rarely

Cane or walker?

At least once a month

No difficulty

Prosthetic or artificial limb?

Some difficulty

Do you have any difficulty concentrating,
remembering, or making decisions?

Much difficulty

At least once a week
Daily

21.

Yes

No

A lot of difficulty
Deaf