Download:
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pdfEmail invitation &
Reminder
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: VA Health Care Experience Survey (5 minutes)
EMAIL PREHEADER: Tell us about your experience at
on
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Your opinion matters.
Dear ,
We care about your experience with VA. Please take this 5
minute survey to let us know about your
experience at on . The more information you share with us, the
better we can serve you.
[If LOB=“Primary Care” and TypeofService≠“Vaccination” display
]
[If LOB=“Primary Care” and TypeofService=“Vaccination” display ]
[If LOB=“Mental Health” display ]
[If LOB=“Pharmacy” display ]
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
We are asking for this information so that you can provide compliments, recommendations, or
concerns to VA. By filling out this survey, you are authorizing VA database access to retrieve
Veteran contact information to follow up with you accordingly for purposes of service recovery,
potential crisis, or to learn more about feedback you have shared regarding your experience with
VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the
final scores truly and accurately represent the experiences of Veterans.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of
1995. Title 38, United States Code, allows us to ask for this information. We estimate that you will
need an average of five minutes to review the instructions and complete this survey. The results of
this survey will be used to inform opportunities for program improvement in the quality of VA
services. Participation in this survey is voluntary, and your decision not to respond will have no
impact on VA benefits or services which you may currently be receiving. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain.
Information gathered will be kept private to the extent provided by law.
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: We still want to hear about your VA Health Care experience (5 minutes)
EMAIL PREHEADER: Tell us about your experience at on
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Your feedback is important to us.
Dear ,
We still want to hear about your experience with VA.
Please take this 5 minute survey to let us know about your
experience at on
. The more
information you share with us, the better we can serve you.
[If LOB=“Primary Care” and TypeofService≠“Vaccination” display
]
[If LOB=“Primary Care” and TypeofService=“Vaccination” display ]
[If LOB=“Mental Health” display ]
[If LOB=“Pharmacy” display ]
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 1 (800) 273-8255 (Press 1), or text 838255 to receive confidential support 24/7
(System of Records Notice VA158VA10NC5). Visit https://www.veteranscrisisline.net for
more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
We are asking for this information so that you can provide compliments, recommendations, or
concerns to VA. By filling out this survey, you are authorizing VA database access to retrieve
Veteran contact information to follow up with you accordingly for purposes of service recovery,
potential crisis, or to learn more about feedback you have shared regarding your experience with
VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the
final scores truly and accurately represent the experiences of Veterans.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of
1995. Title 38, United States Code, allows us to ask for this information. We estimate that you will
need an average of five minutes to review the instructions and complete this survey. The results of
this survey will be used to inform opportunities for program improvement in the quality of VA
services. Participation in this survey is voluntary, and your decision not to respond will have no
impact on VA benefits or services which you may currently be receiving. VA cannot conduct or
sponsor a collection of information unless a valid OMB control number is displayed. You are not
required to respond to a collection of information if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain.
Information gathered will be kept private to the extent provided by law.
Screener Page - All
surveys
DRAFT
DRAFT <05/29/20>
<07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Help us serve you better.
We want to hear about your recent service experience at VA on
. By indicating how much you agree
or disagree with the statements below, you directly help us improve VA
services.
This survey should take you approximately 5 minutes to complete.
Why did you make contact with and seek service from VA on for your ? Required
[If LOB=“Primary Care” and TypeofService≠“Vaccination” display
visit]
[If LOB=“Primary Care” and TypeofService=“Vaccination” display ]
[If LOB=“Mental Health” display visit]
[If LOB=“Pharmacy” display ]
I had a sudden or new (acute) health concern
I had to address an existing (chronic) health concern
On , how did you initially reach out to VA about this
concern? Required
[1]
I called the VA call center
[2]
I called my clinic
[3]
I went to VA in-person to see someone
[4]
During a scheduled appointment, my provider referred me to this service
[5]
Online (myHealtheVet, secure messaging, self-scheduling, chatbot, etc.)
[If respondent selects 1, 2, or 5, display “Phone Request Survey” as page 2]
[If respondent selects 3 display “In-Person Request Survey” as page 2]
[If respondent selects 4 display “Provider-Referred Survey” as page 2]
Did you have an established healthcare provider at VA on ? Required
Yes – I currently receive regularly scheduled care at VA
No – I do not OR no longer receive regularly scheduled care at the VA
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
Core Survey - Phone
or Online Request
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Help us serve you better.
We want to hear about your recent service experience on . By indicating how much you agree or disagree
with the statements below, you directly help us improve VA services.
This survey should take you approximately 5 minutes to complete.
On , I was able to self-assess the urgency of my
health need and determine what to do next. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
When assessing my need to see someone that day, I knew which part of VA to contact
for help. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
When I contacted VA about my need, I was able to get ahold of someone that same day.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I trusted the person I spoke with to take appropriate action or guide my journey on what
to do next. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
The person I spoke to at VA made me feel welcome and took my concern seriously.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I was ultimately able to reach someone at VA I felt was qualified to evaluate my concern
that day. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
My need was addressed that day or I felt reassured it would be addressed at a future
date. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I felt that the person who addressed or resolved my issue that day gave me the best
options to do so. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I am satisfied with VA's ability to provide access to health services the same day I need
them. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
This interaction increased my confidence in accessing same day health services at VA.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience on ?
Please select from one of the following options.
Select your response
Use the text box below to provide details about your experience. Please do not include any
personally identifiable information, Social Security Number, Veteran ID, or medical
information.
0/400
Can VA contact you about your feedback?
Yes, VA can contact me about my patient experience.
No, I do not want VA to contact me about my patient experience.
Would you like to volunteer your demographic information to help VA better serve you?
Yes [Logic proceed to Demographics page]
No
[Logic skip Demographics page]
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
Core Survey - In
Person Request
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Help us serve you better.
We want to hear about your recent service experience on . By indicating how much you agree or disagree
with the statements below, you directly help us improve VA services.
This survey should take you approximately 5 minutess to complete.
On , I was able to self-assess the urgency of my
health need and determine what to do next. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
When assessing my need to see someone that day, I knew which part of VA to contact
for help. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
The person I spoke to at VA made me feel welcome and took my concern seriously.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I was ultimately able to reach someone at VA I felt was qualified to evaluate my concern
that day. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
My need was addressed that day or I felt reassured it would be addressed at a future
date. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I felt that the person who addressed or resolved my issue that day gave me the best
options to do so. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I am satisfied with VA's ability to provide access to health services the same day I need
them. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
This interaction increased my confidence in accessing same day health services at VA.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience on ?
Please select from one of the following options.
Select your response
Use the text box below to provide details about your experience. Please do not include any
personally identifiable information, Social Security Number, Veteran ID, or medical
information.
0/400
Can VA contact you about your feedback?
Yes, VA can contact me about my patient experience.
No, I do not want VA to contact me about my patient experience.
Would you like to volunteer your demographic information to help VA better serve you?
Yes [Logic proceed to Demographics page]
No
[Logic skip Demographics page]
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
Core Survey Provider Initiated
SDS
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Help us serve you better.
We want to hear about your recent service experience on . By indicating how much you agree or disagree
with the statements below, you directly help us improve VA services.
This survey should take you approximately 5 minutes to complete.
I felt that the person who addressed or resolved my issue that day gave me the best
options to do so. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I am satisfied with VA's ability to provide access to health services the same day I need
them. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
This interaction increased my confidence in accessing same day health services at VA.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience on ?
Please select from one of the following options.
Select your response
Use the text box below to provide details about your experience. Please do not include any
personally identifiable information, Social Security Number, Veteran ID, or medical
information.
0/400
Can VA contact you about your feedback?
Yes, VA can contact me about my patient experience.
No, I do not want VA to contact me about my patient experience.
Would you like to volunteer your demographic information to help VA better serve you?
Yes [Logic proceed to Demographics page]
No
[Logic skip Demographics page]
Next
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
Demographics &
Thank you
Day Services>
DRAFT
DRAFT
<07/01/20>
Working Draft, Pre-Decisional, Deliberative document –- Internal
Internal VA
VA Use
Use Only
Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Help VA improve its services.
We are working to better understand our customers. The following
questions are voluntary. By providing your data, your responses can help
us improve VA care and services. Thank you for your participation.
Are you Hispanic or Latino?
Yes
No
How would you describe your race? (Please select all that apply)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
How would you describe your gender?
Male
Female
Non-Binary/Third Gender
Prefer not to say
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
DRAFT <07/01/20>
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 5 minutes
Thank you for taking the time to
help VA serve Veterans better.
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience with
VA services.
Please visit VA.gov/samedayservices to learn more about VA’s same day
health service offerings.
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. VA may utilize individual Veteran survey data from this survey or other sources to ensure the final
scores truly and accurately represent the experiences of Veterans. This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Title 38, United States Code, allows us to ask for this information. We
estimate that you will need an average of 5 minutes to review the instructions and complete this survey. The results of this
survey will be used to inform opportunities for program improvement in the quality of VA services. Participation in this survey
is voluntary, and your decision not to respond will have no impact on VA benefits or services which you may currently be
receiving. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are
not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be
located on the OMB Internet Page at https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private
to the extent provided by law.
Privacy Policy
| File Type | application/pdf |
| File Modified | 2020-07-01 |
| File Created | 2020-07-01 |