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
Zip Code You Live In: ____________________
Year of Birth: ________
Gender (what would you describe yourself as):
Male Female Transgender None of these Prefer not to answer
Active Duty Period of Service (indicate years only): _______ to ________
Branch [check all that apply]:
Army Navy Air Force Marines Coast Guard Reserve Component National Guard
Reserve or National Guard Period of Service (indicate years only): _____ to _______
Rank (at discharge) [check all that apply]: Officer Enlisted
Did You Serve in a Combat Theater? Yes No
If yes, please specify the location(s)___________________________________________________________
Current Marital Status
Single, never married Married Divorced Separated Widowed
Prefer not to answer
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
Ethnicity:
Hispanic or Latino Not Hispanic or Latino Prefer not to Answer
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
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_____________________
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
Do you have a VA- recognized service-connected disability? Yes No
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
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
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
Suggestions to decrease the burden for this survey and other questions or comments can be sent to CoverCommission@va.gov.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |