2900-0876-AA2-4 COVID-19 Vaccine Trial VA.Gov

Clearance for A-11 Section 280 Improving Customer Experience Information Collection

COVID-19 VACCINE TRIAL_VA.GOV_V5.A_102920

COVID-19 Vaccine Survey

OMB: 2900-0876

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 2900-0876 can be found here:

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COVID-19 Vaccine Trial - VA.GOV
V5 DRAFT
10/29/20

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: 2 minutes

Help us serve you better.
We want to hear about your recent experience with the VA COVID-19
Research website. By indicating how much you agree or disagree with
the statements below, you directly help us improve VA services.
This survey should take approximately 2 Minutes to complete.
How did you hear about the VA COVID-19 Research website?
(Select all that apply) Required
I received an email from VA/ Million Veterans Program
I saw social media posts
I saw it on the VA Newsletter
I heard from my Veterans Service Officer (VSO)
I was referred by my Doctor
I was referred by a Servicemember or fellow Veteran
Other
What about the VA COVID-19 Research email caused you to register? Required
I usually open emails VA sends me
I found the subject line of the email interesting
I was curious about VA COVID-19 research
I usually click the website links the VA sends to me
Other
[Sub question is only presented if user selects option 1 for prior queston]

Please select the reason(s) you decided to become a research volunteer.
(Select all that apply) Required
I wanted to learn more about VA COVID-19 research studies
I wanted to help the VA find a cure or vaccine for COVID-19
I wanted to protect myself and my family members against COVID-19
I wanted to be able to join one of the VA COVID-19 studies
I filled out the information because VA was asking
I wanted to possibly get early access to a new vaccine
I wanted to receive more regular health check-ins as part of the study
Other
Please tell us how much you agree or disagree with this statement: “The information on
VA COVID-19 Research website was easy for me to understand”. (For example, study
details, time and commitment, compensation, and risks) Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

Please tell us how much you agree or disagree with this statement: The VA Research
website with information about current research projects is a good way to learn about
VA research volunteer opportunities. Required
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

Please select additional VA research topics you would be interested in learning about.
(Select all that apply) Required
Cancer
Diabetes
Infectious diseases
Heart diseases
HIV/AIDS
Aging
Post-Traumatic Stress Disorder (PTSD)
Traumatic Brain Injury (TBI)
Gulf war
Burn pits
Agent Orange
Suicide prevention
Other mental health
Other
Do you think you would have volunteered to be contacted for a COVID study without the
VA COVID-19 Research website? Required
Yes
No
Have you ever previously participated in VA research study? Required
Yes
No
Can VA contact you about your feedback?
Yes, VA can contact me about my feedback.
No, I do not want VA to contact me about my feedback.
Finish

We are asking for this information so that you can provide compliments, recommendations, or concerns to VA.1 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.2 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 2 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.
[Logic: 1). Required if Service Recovery. 2). Required unless exception.]

COVID-19 Vaccine Trial
V5 DRAFT
10/29/20

OMB Number: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 2 minutes

Thank you for choosing VA.
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 to explore benefits, resources, and information
at VA.

File Type	application/pdf
File Modified	2020-11-03
File Created	2020-11-03