COVER Commission Focus Group Veterans Demographics Survey

Creating Options for Veterans Expedited Recovery (COVER) Commission Veterans Focus Groups: Mental Health Services Preferences and Utilization Data Collection

COVER Comm_Veterans Demographics Survey_OMB passback revision_06172019_FINAL

COVER Commission Focus Group Veterans Demographics Survey

OMB: 2900-0868

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OMB Control Number: 2900-____

Estimated Burden: 5 minutes

Expiration Date: 06/30/2022


COVER COMMISSION

Paperwork Reduction Act Statement: This information is being collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 to complete this survey will average 5 minutes. This includes the time needed to follow instructions, gather the necessary facts, and respond to the questions. This information is being collected to better understand characteristics of the participants in the Focus Groups. The results of this survey will help inform improvements in the quality of service delivery by providing additional background information about the participants to better serve them. Participation in this survey is voluntary, and failure to respond will not have any impact on your entitlement to benefits.

Privacy Act Statement: Information gathered will be kept private to the extent provided by law. Data collected will be aggregated, and no information will be attributable to you as an individual. Disclosure of information will involve release of statistical data and other non-identifying data for improving the quality of service delivery by providing additional background information about the participants to better serve them. Participation in this survey is voluntary, and failure to respond will not have any impact on your entitlement to benefits.



Some Information About You


  1. Zip Code You Live In: ____________________


  1. Year of Birth: ________


  1. Gender (what would you describe yourself as):


Male Female Transgender None of these Prefer not to answer


  1. Active Duty Period of Service (indicate years only): _______ to ________


  1. Branch [check all that apply]:


Army Navy Air Force Marines Coast Guard Reserve Component National Guard


  1. Reserve or National Guard Period of Service (indicate years only): _____ to _______


  1. Rank (at discharge) [check all that apply]: Officer Enlisted


  1. Did You Serve in a Combat Theater? Yes No


    1. If yes, please specify the location(s)___________________________________________________________





  1. Current Marital Status


Single, never married Married Divorced Separated Widowed

Prefer not to answer


  1. Household income before taxes in 2018:


Under $20,000

$20,001 - $30,000

$30,001 - $40,000

$40,001 - $50,000

$50,001 - $60,000

$60,001 - $75,000

Greater than $75,000

Prefer not to answer


  1. Ethnicity:


Hispanic or Latino Not Hispanic or Latino Prefer not to Answer


  1. Race:


American Indian or Alaska Native Asian Black or African American

Native Hawaiian or Other Pacific Islander Some other race

Two or more races White



  1. Last Grade Completed in School:


Did not complete High School  High School graduate  G.E.D.  Some College

Associate’s Degree  Bachelor’s Degree  Graduate or Professional Degree

Other_____________________



  1. Current Employment Status [check all that apply]


Employed Full-time Employed Part-time Disabled, unable to work

Unemployed – Seeking Employment Unemployed – Not Seeking Employment

Retired Full or Part Time Student



  1. Do you have a VA- recognized service-connected disability? Yes No



  1. If you are eligible to receive your mental health care through the VA, do you receive care or services from a Department of Veterans Affairs health facility? This includes care at CBOCs and Vet Centers.


All Most Some None  I don’t know



  1. How much of your mental health care do you receive from a Department of Veterans Affairs health facility? This includes care at CBOCs and Vet Centers.


All Most Some None  I don’t know


  1. Do you receive any care or services for mental health conditions in the community through the VA Choice program?


Yes No Maybe I don’t know




*THANK YOU VERY MUCH FOR YOUR TIME AND CONTRIBUTION*



Suggestions to decrease the burden for this survey and other questions or comments can be sent to CoverCommission@va.gov.


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