Download:
pdf |
pdfOMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
National Disabled Veterans
Winter Sports Clinic
OMB 2900-XXXX
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of
1995. Accordingly, VA 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 complete this survey will average 2.5 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. The results of this survey will lead to
improvement in the quality of service delivery by helping to shape the direction and focus of specific
programs and services. Submission of this form is voluntary and failure to respond will have no impact
on benefits to which you may be entitled.
Privacy Act. Assurances of privacy are contained in 38 U.S.C. 5701 and 7332. The information
collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974.
These forms are part of the system of records identified as 121VA19 “National Patient Database – VA”
and 57VA135 “Voluntary Service Records – VA” as set forth in the Compilation of Privacy Act Issuances
via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
National Disabled Veterans Winter Sports Clinic
Thank you for agreeing to take this survey. Your responses will be kept in confidence
and will only be reported in aggregate. Your participation will provide us with important
information that will be used to better serve our Veterans.
1. What is your age?
17-25
26-35
36-45
46-55
56-64
65-74
75+
2. Are you…?
Male
Female
3. In which era did you serve? Please select all that apply.
OEF/OIF
Desert Storm
Korea
Vietnam
World War II
Other
4. Do you have a VA-rated Service Connected Disability?
Yes
No
5. Nature of illness/injury (choose PRIMARY one):
Traumatic Brain Injury (TBI)
Post-Traumatic Stress Disorder (PTSD)
Spinal Cord Injury (SCI)
Quadriplegic SCI Paraplegic SCI
Multiple Sclerosis
Amputation
Visual Impairment
Stroke
Other
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
6. How many years have you ad this illness/injury?
< 1 year
1-2 years
6-15 years
16-25 years
3-5 years
25+ years
7. Do you use a wheelchair or prosthetic limb on a daily basis?
Wheelchair
Prosthetic limb
Neither
8. Which of the following VA National Veterans Sports Programs & Special Events
have you participated in, if any? Please check all that apply.
National Veterans Creative Art Festival
National Disabled Veterans Winter Sports Clinic
National Veterans Golden Age Games
National Veterans TEE Tournament
National Veterans Wheelchair Games
National Veterans Summer Sports Clinic
9. For how many years have you participated in any VA National Veterans Sports
Programs & Special Events?
This is my first event
2-5
6-10
11+
10. For how many years have you participated in the National Disabled Veterans Winter
Sports Clinic?
This is my first year
2-5
6-10
11+
11. How often do you participate in sports activities?
Daily
Seasonally
Weekly
Not at all
Monthly
12. How do you engage in sports or recreation programs? Please check all that apply.
VA programs
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
Veteran Service Organization sports programs
Community based sports & recreation programs
Individually / on my own
I don’t regularly engage in sports / recreation
Other
13. Which of the following, if any, does your VA therapist do to support your
participation in sports and recreation at home? (Check ALL that apply)?
Provide resources for community organizations
General orientation
Organized practices
Skills instruction
Equipment
None of the above
Other
14. For how many months, if any, did you train in preparation for this event?
11+ months prior to event
8-10 months prior to event
4-7 months prior to event
1-3 months prior to event
I did not train for the event
15. How likely are you to continue involvement in one or more of these sports when
you return home.
I definitely will not
I possibly will
I probably will
I definitely will
16. Please indicate the extent to which you agree or disagree with the following
statement: “Preparation and participation in the National Disabled Veterans Winter
Sports Clinic has taught me ways to be active in recreation in my home
community.”
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
17. To what extent would each of the following help you to be more involved in sports
on a regular basis? Please use the following rating scale.
1. Would not help
2. Some help
3. A fair amount of help
4. A lot of help
5. A tremendous amount of help
____ Education of community programs available in my area
____ Adaptive sports clinics to develop skills
____ VA staff support to introduce me to a local program for the first time
____ Adaptive equipment
18. Thinking specifically about this event, what is the SINGLE most important reason
you participated in this event?
Improve or maintain health.
Help other Veterans – peer mentor, advocate for new injuries and help with
adjustment.
Enhance / develop a social network.
Learn new adaptive sports & recreation activities.
Continue my rehabilitation.
Other (please specify)
19. When you participate in leisure activities, do you usually do this alone or with
others?
(Choose ONE answer)
Mostly alone
Mostly with friends
Mostly with family members
With a combination of family and friends
I do not participate in leisure activities, such as movies, sports, restaurants, etc.
20. To what extent did each of the following influence your decision to participate in
this event? Please use the following rating scale.
1. No impact
2. Slight impact
3. Moderate impact
4. Major impact
____ My doctor or therapist recommended it
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
____ I enjoy sports
____ I am an active person
____ I am concerned about staying healthy
____ I like to compete in sports events with other Veterans
____ I like the interaction with other Veterans
____ I want to gain experience with different sports
____ My friend or family member encouraged me to participate
____ Other
21. What type of Skiing will you be participating in during the NDVWSC 2014?
Downhill (Alpine)
Cross Country (Nordic)
22. What level of skier do you consider yourself to be?
Beginner
Intermediate
Advanced
23. What other events are you registered for?
Snowmobiling
Sled Hockey
Glenwood Hot Springs
Scuba Diving
Snowshoeing
Aspen Trip/Gondola Ride
Curling
Kayaking
Fishing
Climbing Wall
Educational Workshops
24. What goal (s) are you setting specific to skiing?
☒ Learn to Ski
☐Gain knowledge of adaptive equipment (What is available, How to secure my
own equipment)
☒Advance my existing skills (circle one) Beginner to Intermediate
Intermediate to Advance
Advanced to Independent
☐Total independence
VA Form 10107
DEC 2013
OMB 2900-XXXX
Estimated Burden: 2.5 minutes
Expiration Date: XX-XX-XXXX
25. Since the Winter Sports Clinic, do you:
Exercise much less
Exercise somewhat less
Have not changed my level of exercise
Exercise somewhat more
Exercise much more
26. As a result of participating in the Winter Sports Clinic:
Strongly
Agree
Neutral
Disagree
Agree
I know more about adaptive sports, resources and opportunities.
Strongly
Disagree
I feel more independent.
I am motivated to be more involved in sports and recreation.
I am able to overcome barriers to participate in activities I want.
27. What did you like MOST about the participation in Winter Sports Clinic? Why?
28. What ONE thing, if anything, about the Winter Sports Clinic would you change?
29. Is there any other feedback you’d like to provide:
VA Form 10107
DEC 2013
| File Type | application/pdf |
| File Title | Report Template |
| Author | Benefits Assistance Service |
| File Modified | 2014-03-24 |
| File Created | 2014-03-24 |