Form 10-21034G SURVEY OF VETERAN ENROLLEES� HEALTH AND RELIANCE UPON VA

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
INTENDED AUDIENCE: Priority 1 through 8 veterans who have applied or are currently enrolled for VA
health care services.
TIME BEGUN____________________________
Hello, my name is I’m calling on behalf of VA, the Department of
Veteran Affairs. May I speak with ?
01
02
03
04
05
06

(SKIP TO INTRO) RESPONDENT AVAILABLE
(SKIP TO CALLBACK) RESPONDENT NOT AVAILABLE
(SKIP TO PROXY) RESPONDENT UNABLE TO DO INTERVIEW
PHYSICAL/MENTAL HEALTH REASON
DO NOT KNOW RESPONDENT/DO NOT RECOGNIZE NAME – MAKE A WRONG NUMBER
(SKIP TO BADNUM) RESPONDENT NOT AT NUMBER
TERMINATION SCREEN

BADNUM Do you have a telephone number where I might be able to reach ?
01
02
03

YES – MAKE NEW NUMBER DISPOSITION, COLLECT TELEPHONE NUMBER
NO – MAKE NO NUMBER AVAILABLE
NO – WILL NOT RELEASE TELEPHONE NUMBER

INTRODUCTION: We are conducting a study about veteran’s use of health care services and needs.
Your name was randomly selected from a list of veterans who enrolled to use VA health care services.
This study will take 10-15 minutes. Everything we talk about will be confidential, although this call may be
monitored for quality assurance. Your participation is voluntary – you can choose not to answer any
question. Your benefits will not change as a result of your answering any questions. If you chose not to
participate, or answer a question, your benefits will also not be affected. However, your participation is
important for this study’s success – we need to talk to veterans like you. Would now be a good time?
IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and
what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect
your identity and answers to the extent allowed under the law. Your answers will in no way affect your
benefits. No information that you provide will be released to the general public in a way that can be traced
back to you.
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the
VHA Office of the Assistant Deputy Under Secretary for Health and the Office of Management and
Budget. If you have any questions regarding the legitimacy of this survey, you may call _________ at the
Department of Veterans Affairs in Washington, D.C. at ___ ___ ___.
PROXY We are conducting a study about veteran’s use of health care services and needs. was randomly selected from a list of veterans who enrolled to use VA health care services. This
is an important study, would you be able to answer questions about ’s health care,
insurance and health status?
IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and
what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect
your identity and answers to the extent allowed under the law. Your answers will in no way affect your
benefits. No information that you provide will be released to the general public in a way that can be traced
back to you.

VA Form 10-20134g
XXXX 2007

Page 1

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the
VHA Office of the Assistant Deputy Under Secretary for Health and the Office of Management and
Budget. If you have any questions regarding the legitimacy of this survey, you may call _________ at the
Department of Veterans Affairs in Washington, D.C. at ___ ___ ___.
01
02

YES – CREATE VARIABLE “PROXY= 01 IF PROXY INTERVIEW AND 00 IF NOT PROXY”
NO – TERMINATE CREATE DISPOSITIN NO ELIGIBLE PROXY, RESPONDENT UNABLE

98

DON’T KNOW – TERMINATE CREATE DISPOSITION NO ELIGIBLE PROXY, RESPONDENT
UNABLE
REFUSED – TERMINATE PROXY REFUSAL

99

PROXY_2 This study will take 10-15 minutes. Everything we talk about will be confidential, although this
call may be monitored for quality assurance. Your participation on behalf of is voluntary
– you can choose not to answer any question. benefits will not change as a result of
your answering any questions. If you chose not to participate, or answer a question,
benefits will also not be affected. However, your participation on behalf of is important
for this study’s success – we need to talk to veterans like . Would now be a good time?
IF NECESSARY MORE INFORMATION: This survey is about how many veterans use VA services and
what types of services they do or do not use.
IF NECESSARY CONFIDENTIALITY: Your name and answers will be linked. However, VA will protect
your identity and answers to the extent allowed under the law. Your answers will in no way affect your
benefits. No information that you provide will be released to the general public in a way that can be traced
back to you.
ONLY IF LEGITIMACY IS QUESTIONED READ: This survey has been reviewed and approved by the
VHA Office of the Assistant Deputy Under Secretary for Health and the Office of Management and
Budget. If you have any questions regarding the legitimacy of this survey, you may call _________ at the
Department of Veterans Affairs in Washington, D.C. at ___ ___ ___.
01
02

(SKIP TO RESIDE) YES
(SKIP TO CALLBACK) NO

RESIDE Does still live at this telephone number or somewhere else?
01
02

(SKIP TO RELATION) STILL AT LOCATION
DIFFERENT LOCATION

98
99

DON’T KNOW
REFUSED

RESIDE_1 In what state does live?
/PROVIDE LIST OF STATE NAMES/
98
99

DON’T KNOW
REFUSED

RELATION Before we begin, could you tell me how you would describe your relationship to ? I am going to read you a list. Are you ’s…
01

Spouse

VA Form 10-20134g
XXXX 2007

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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
02
03
04
05
06
07
08
09
10

Significant other
Parent
Sibling
Child
Some other relative
Friend
Caregiver
Guardian or Attorney
Social Worker or Case Worker

97
98
99

Some other relation
DON’T KNOW
REFUSED

CALLBACK When would be a convenient time to call back and speak with ?
/IF PROXY=01/ When would be a convenient time to call back ?
01
02

MAKE APPOINTMENT 104
CALL BACK ANYTIME 105

PREQ1 Many of the following questions may be simply answered as either yes or no. However, if
you are unsure about it, just let me know and I will note that.

Next , I will be asking you about use of medical or mental health services in from both Non-VA
sources, as well as from VA. First, my questions are about Non-VA provided Health Care
Services.
/IF PROXY=01/ Next, I will be asking you about ’s use of medical or
mental health services in from both Non-VA sources, as well as from VA. First, my
questions are about Non-VA provided Health Care Services.
Q1.
In 2007, did you use any medical or mental health care services that were not provided by or
paid for by VA? Please include ANY service at all, such as a flu shot, a single prescription, a test of some
sort, etc.
/IF PROXY=01/ In 2007, did use any medical or mental health care services
that were not provided by or paid for by VA? Please include ANY service at all, such as a flu
shot, a single prescription, a test of some sort, etc.
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF
SPONTANEOUSLY VOLUNTEERED BY RESPONDENT.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
00
01
02

(SKIP TO Q25) NO NEED FOR SERVICES AT ALL
(SKIP TO Q2) YES
NO

98
99

DON’T KNOW
REFUSED

//IF Q1=2, 98, 99 AND [----------has non-VA health insurance] THEN ASK, ELSE SKIP TO Q14//

VA Form 10-20134g
XXXX 2007

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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
Q1a. VALIDATION: I earlier I thought you said that you do have some type of Non-VA medical
coverage. Just to make sure I have this right, I want to confirm that in 2007, you never received any type
of medical service, including flu shot, prescription, physical check-up or test or mental health services or
assistance that was not provided or paid for by VA.
/IF PROXY =01/ I earlier I thought you said that does have some type of NonVA medical coverage. Just to make sure I have this right, I want to confirm that in 2007, never received any type of medical service, including flu shot, prescription, physical
check-up or test or mental health services or assistance that was not provided or paid for by VA.
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF
SPONTANEOUSLY VOLUNTEERED BY RESPONDENT.]
00
01
02

(SKIP TO Q25) NO NEED FOR SERVICES AT ALL
(SKIP TO Q2) DID USE NON-VA SERVICE
(SKIP TO Q14) CONFIRMED THAT NO NON-VA CARE RECEIVED

98
99

(SKIP TO Q14) DON’T KNOW/CAN’T REMEMBER
(SKIP TO Q14) REFUSED

Q2.
In 2007, did you stay overnight at any Non-VA Medical Hospital or a Non-VA Mental Health
Facility?
/IF PROXY=01/ In 2007, did stay overnight at any Non-VA Medical Hospital or
a Non-VA Mental Health Facility?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
01
02

YES
(SKIP TO Q11) NO

98
99

(SKIP TO Q11) DON’T KNOW/DON’T REMEMBER
(SKIP TO Q11) REFUSED

Q3.

Were any of these stays paid for or provided by VA?
/IF PROXY=01/ Were any of these stays paid for or provided by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PORTION.]
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT OR ADMISSION INTO AND
DISCHARGE OUT OF THE HOSPITAL.]

01
02

YES
(SKIP TO Q5) NO

98
99

(SKIP TO Q5) DON’T KNOW
(SKIP TO Q5) REFUSED

Q4.

Were any of these stays not paid for or provided by VA?
/IF PROXY=01/ Were any of these stays not paid for or provided by VA?

VA Form 10-20134g
XXXX 2007

Page 4

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PORTION.]
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]
01
02

YES
(SKIP TO Q11) NO, ALL VA PROVIDED

98
99

(SKIP TO Q11) DON’T KNOW/ DON’T REMEMBER
(SKIP TO Q11) REFUSED

PREQ5/IF Q4=01, ELSE GOTO Q11/ For the next group of questions, I would like you to only think about
all of the stays you have just mentioned that were not paid for by VA.
/IF PROXY=01 AND IF Q4=01, ELSE GOTO Q11/ For the next group of questions, I would like
you to only think about all of ’s stays you have just mentioned that were not
paid for by VA.
Q5.
In 2007, how many overnight stays, if any, did you have at any Non-VA Medical Hospital. Please
do not count stays for mental health or substance abuse treatment?
/IF PROXY=01/ In 2007, how many overnight stays, if any, did have at any
Non-VA Medical Hospital. Please do not count stays for mental health or substance abuse
treatment?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE= 0 – 366]

/IF Q5=0, 98, OR 99 GOTO Q8, ELSE CONTINUE/
Q6.

/IF Q5=1, ASK/ How many nights was that stay?
/IF Q5>1 ASK/ How many nights was your first stay?
/IF PROXY=01 AND Q5=1, ASK/ How many nights was that stay?
/IF PROXY=01 AND Q5>1 ASK/ How many nights was ’s first stay?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]

01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE= 0 – 366]

/IF Q5=1 GOTO Q8/
Q7.

/IF Q5>1 ASK/ In 2007, how many nights in total did you stay in a Non-VA Hospital on your 2nd
through /Q5/ stays?
/IF PROXY=01 AND Q5>1 ASK/ In 2007, how many nights in total did stay in a
Non-VA Hospital on the 2nd through /Q5/ stays?

VA Form 10-20134g
XXXX 2007

Page 5

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]
[INTERVIEWER NOTE: THIS IS THE TOTAL NUMBER OF NIGHTS FOR ALL STAYS. IF
NECESSARY WALK THEM THROUGH THE MATH.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

Q8.

In 2007, how many stays for mental health or substance abuse treatment, if any, did you have at
any Non-VA Mental Health Facility, or other Non-VA medical facility? Please do not count any
stays paid for by VA.

[RANGE=0 –366]

/IF PROXY=01/ In 2007, how many stays for mental health or substance abuse treatment, if any,
did have at any Non-VA Mental Health Facility, or other Non-VA medical
facility? Please do not count any stays paid for by VA.
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0- 366]

/IF Q8=0, 98, 99 GOTO Q11, ELSE CONTINUE/
Q9.

/IF Q8=1 ASK/ How many nights was that stay?
/IF Q8>1 ASK/ How many nights was your first stay?
/IF PROXY=01AND Q8=1 ASK/ How many nights was that stay?
/IF PROXY=01 AND Q8>1 ASK/ How many nights was ’s first stay?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]

01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0- 366]

/IF Q8=1 GOTO Q11, ELSE CONTINUE/
Q10.

In 2007, how many nights in total did you stay in a Non-VA Facility for mental health or
substance abuse treatment on your second through /Q8 RESPONSE/ stays?
/IF PROXY=01/ In 2007, how many nights in total did stay in a Non-VA
Facility for mental health or substance abuse treatment on the second through /Q8 RESPONSE/
stays?

VA Form 10-20134g
XXXX 2007

Page 6

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL.]
[INTERVIEWER NOTE: THIS IS THE TOTAL NUMBER OF NIGHTS FOR ALL STAYS. IF
NECESSARY WALK THEM THROUGH THE MATH.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

Q11.

In 2007, how many outpatient visits or trips, did you make to any Non-VA doctor’s office, hospital,
or outpatient clinic? Please do not count dental, mental health, substance abuse visits or any
visits paid for by VA?

[RANGE=0 -366]

/IF PROXY=01/ In 2007, how many outpatient visits or trips, did make to any
Non-VA doctor’s office, hospital, or outpatient clinic? Please do not count dental, mental health,
substance abuse visits or any visits paid for by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0- 366]

Q12. In 2007, how many home health care visits, if any, were made to you by Non-VA providers or not
paid for by VA?
/IF PROXY=01/ In 2007, how many home health care visits, if any, were made to by Non-VA providers or not paid for by VA?
[INTERVIEWER NOTE: THIS IS THE SUM OF ALL INDIVIDUAL PROVIDER’S VISITS.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER:

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

Q13. In 2007, how many outpatient visits or trips for mental health or substance abuse treatment did
you make to a Non-VA Mental Health or Substance Abuse Facility or Doctor’s office? Please do not count
visits paid for by VA.
/IF PROXY=01/ In 2007, how many outpatient visits or trips for mental health or substance abuse
treatment did make to a Non-VA Mental Health or Substance Abuse Facility or
Doctor’s office? Please do not count visits paid for by VA.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER:

98
99

DON’T KNOW
REFUSED

VA Form 10-20134g
XXXX 2007

[RANGE=0-366]

Page 7

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
PREQ14 Now, the next few questions are in regards to any VA provided Healthcare.
Q14.
In 2007, did you use any VA healthcare services, or did you have any of your health care paid
for by VA?
/IF PROXY=01/ In 2007, did use any VA healthcare services, or did have any health care paid for by VA?
IF NECESSARY: Please include ANY service at all such as a flu shot, a single prescription, a
test, etc…
[INTERVIEWER NOTE: “NO NEED FOR SERVICES AT ALL” ONLY MARK IF
SPONTANEOUSLY VOLUNTEERED BY RESPONDENT.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
00

(SKIP TO Q25) NO NEED FOR SERVICES AT ALL

01
02

YES
NO

98
99

DON’T KNOW
REFUSED

Q14 VALIDATION: /IF Q14=02 0R 98 OR 99 ASK, ELSE CONTINUE/ Just to make sure I have this
correct, in you did not receive ANY health care services at all from VA. You did not get a flu shot, a
single prescription, any tests, to any other health care service for which VA paid any portion of?
/IF PROXY=01 AND IF Q14=02 0R 98 OR 99 ASK, ELSE CONTINUE/ Just to make sure I have
this correct, in 2007 did not receive ANY health care services at all from VA.
did not get a flu shot, a single prescription, any tests, to any other health care
service for which VA paid any portion of?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01
02

(SKIP TO Q25) YES
NO

98
99

(SKIP TO Q25) DON’T KNOW
(SKIP TO Q25) REFUSED

Q15.

In 2007, did you stay overnight at any VA Medical Hospital or a VA Mental Health Facility, or
have any stays at Non-VA facilities that were paid for by VA?
/IF PROXY=01/ In 2007, did stay overnight at any VA Medical Hospital or a VA
Mental Health Facility, or have any stays at Non-VA facilities that were paid for by VA?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]

01
02

YES
(SKIP TO Q22) NO

VA Form 10-20134g
XXXX 2007

Page 8

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
98
99

(SKIP TO Q22) DON’T KNOW
(SKIP TO Q22) REFUSED

Q16. In 2007, how many total overnight stays, if any, did you have at a VA Medical Hospital, or a
medical hospital paid for by VA? Please do not count stays for mental health and substance abuse
treatment?
/IF PROXY=01/ In 2007, how many total overnight stays, if any, did have at a
VA Medical Hospital, or a medical hospital paid for by VA? Please do not count stays for mental
health and substance abuse treatment?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

/IF Q16=0, 98, 99 GOTO Q19, ELSE CONTINUE/
Q17.

/IFQ16=1 ASK/ How many nights was that stay?
/IF Q16>1 ASK/ How many nights was that first stay?
/IF PROXY=01 AND Q16=1 ASK/ How many nights was that stay?
/ IF PROXY=01 AND Q16>1 ASK/ How many nights was ’s first stay?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]

01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

/IF Q16=1 GOTO Q19, ELSE CONTINUE/
Q18.

In 2007, how many nights in total did you stay in a VA Medical Hospital or other hospitals paid
for by VA on your second through /Q16 RESPONSE/ stays?
/IF PROXY=01/ In 2007, how many nights in total did stay in a VA Medical
Hospital or other hospitals paid for by VA on the second through /Q16 RESPONSE/ stays?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]

VA Form 10-20134g
XXXX 2007

Page 9

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[INTERVIEWER NOTE: THIS IS THE TOTAL NUMBER OF NIGHTS FOR ALL STAYS. IF
NECESSARY WALK THEM THROUGH THE MATH.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

Q19.

In 2007, how many overnight stays, if any, did you have for mental health or substance abuse
treatment at a VA Facility or at a facility paid for by VA?

[RANGE=0 -366]

/IF PROXY=01/ In 2007, how many overnight stays, if any, did have for mental
health or substance abuse treatment at a VA Facility or at a facility paid for by VA?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

/IF Q19=0, 98, 99 GOTO Q22, ELSE CONTINUE/
Q20.

/ IF Q19 =1 ASK/ How many nights was that stay?
/IF Q19>1 ASK/ How many nights was your first stay?
/IF PROXY=01 AND Q19 =1 ASK/ How many nights was that stay?
/IF PROXY=01 AND Q19>1 ASK/ How many nights was ’s first stay?
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]

01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

/IF Q19=1 GO TO Q22, ELSE CONTINUE/
Q21.

In 2007, how many nights in total did you stay in a VA Facility, or stays elsewhere that were paid
for by VA for mental health or substance abuse care on your second through /Q19 RESPONSE/
stays?
/IF PROXY=01/ In 2007, how many nights in total did stay in a VA Facility, or
stays elsewhere that were paid for by VA for mental health or substance abuse care on the
second through /Q19 RESPONSE/ stays

VA Form 10-20134g
XXXX 2007

Page 10

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[INTERVIEWER NOTE: “STAY” IS A SINGLE TRIP INTO AND OUT, OR ADMISSION INTO
AND DISCHARGE OUT OF THE HOSPITAL, NOT THE NUMBER OF DAYS THE PATIENT
STAYED IN THE HOSPITAL.]
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
[INTERVIEWER NOTE: THIS IS THE TOTAL NUMBER OF NIGHTS FOR ALL STAYS. IF
NECESSARY WALK THEM THROUGH THE MATH.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

Q22.

In 2007, how many outpatient visits for medical care did you make that were paid for by VA?
That would include the number of times you went to a VA doctor, hospital or clinic for medical
care or received medical care somewhere else that was paid for by VA. Do not count dental or
mental health visits or trips to a pharmacy.

[RANGE=0 -366]

/IF PROXY=01/ In 2007, how many outpatient visits for medical care did make
that were paid for by VA? That would include the number of times went to a
VA doctor, hospital or clinic for medical care or received medical care somewhere else that was
paid for by VA. Do not count dental or mental health visits or trips to a pharmacy.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

Q23.

In 2007, how many home health care visits, if any, were made to you by VA providers or non-VA
providers paid for by VA?

[RANGE=1-366]

/IF PROXY=01/ In 2007, how many home health care visits, if any, were made to by VA providers or non-VA providers paid for by VA?
[INTERVIEWER NOTE: WE ARE LOOKING FOR THE SUM TOTAL OF ALL INDIVIDUAL
PROVIDER VISITS.
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

98
99

DON’T KNOW
REFUSED

[RANGE=0-366]

Q24. In 2007, how many outpatient visits for mental health or substance abuse treatment, if any, did
you make to VA or visits elsewhere that were paid for by VA?
/IF PROXY=01/ In 2007, how many outpatient visits for mental health or substance abuse
treatment, if any, did make to VA or visits elsewhere that were paid for by VA?
[INTERVIEWER NOTE: PAID FOR INCLUDES ANY PART/PORTION OF.]
01

ENTER NUMBER

VA Form 10-20134g
XXXX 2007

[RANGE=0-366]

Page 11

2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
98
99

DON’T KNOW
REFUSED

Q25. I am going to read you a list of possible ways you could use VA for your health care in the future.
Please listen to them all, and then tell me the one that best describes the primary way you plan to use VA
health care in the future. Do you plan to use VA as….
/IF PROXY=01/ I am going to read you a list of possible ways could use VA for
health care in the future. Please listen to them all, and then tell me the one that best describes
the primary way plans to use VA health care in the future. Does plan to use VA as
[INTERVIEWER: PLEASE READ ENTIRE LIST. CHOOSE ONLY ONE.]
01

Your primary source of healthcare;
/IF PROXY=01/ a primary source of healthcare

02

Backup to non-VA care for some minor services
/IF PROXY=01/ As backup to non-VA care for some minor services

03
04
05
06
07

A “safety net” to use only if needed
For prescriptions;
For specialized care
Some other way;
Or do you have No plans to use VA for healthcare
/IF PROXY=01/ Or does have no plans to use VA for healthcare?

98
99

DON’T KNOW
REFUSED

Q25_O /IF Q25=06 ASK, ELSE CONTINUE/ Could you please tell me how you primarily plan to use VA
for health care in the future?
/IF PROXY=01/ Could you please tell me how primarily plans to use VA for
health care in the future?
01

ENTER RESPONSE:

98
99

DON’T KNOW
REFUSED

PREQ26 Now, I’d like to ask you about your current health.
/IF PROXY=01/ Now, I’d like to ask you about ’s current health.
Q26.

Compared to other people your age, would you say your health is:
/IF PROXY=01/ Compared to other people ’s age, would you say ’s health is:
[INTERVIEWER PLEASE READ LIST]

VA Form 10-20134g
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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
01
02
03
04
05

Excellent
Very good
Good
Fair, or
Poor

98
99

DON’T KNOW
REFUSED

The next few questions are about cigarette smoking.
Q27.

Have you smoked at least 100 cigarettes in your entire life?
/IF PROXY=01/ Has smoked at least 100 cigarettes in ’s
entire life?

01
02

YES
(SKIP TO Q30) NO

98
99

DON’T KNOW
REFUSED

Q28.

Do you now smoke cigarettes every day, some days, or not at all?
/IF PROXY=01/ Does now smoke cigarettes every day, some days, or not at
all?

01
02
03

Every day
Some days
Not at all

98
99

DON’T KNOW
REFUSED

Q29. During the past 12 months, have you stopped smoking for more than one day because you were
trying to quit smoking?
/IF PROXY=01/ During the past 12 months, has stopped smoking for more
than one day because was trying to quit smoking?
01
02

YES
NO

98
99

DON’T KNOW
REFUSED

We are almost finished. The last questions are for demographic purposes only.
Q30. Which of the following best describes your current marital status?
/IF PROXY=01/ Which of the following best describes ’s current marital status?
[INTERVIEWER READ LIST.]
01

Married

VA Form 10-20134g
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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
02
03
04
05

Widowed
Divorced
Separated
Single – Never Married

98
99

DON’T KNOW
REFUSED

Q31. /IF Q30=01 OR 04 ASK/ Not including yourself, how many dependents, such as your spouse or
dependent children do you currently have?
/IF Q30 NE 01 OR 04 ASK/ Not including yourself, how many dependents, do you currently
have?
/IF PROXY=01AND Q30=01 OR 04 ASK/ Not including , how many
dependents, such as a spouse or dependent children does currently have?
/IF PROXY=01 AND Q30 NE 01 OR 04 ASK/ Not including , how many
dependents, does currently have?

01

[INTERVIEWER NOTE: “DEPENDENT” IS ANYONE WHO RELIES ON THE RESPONDENT
FOR AT LEAST HALF OF THAT PERSON’S FINANCIAL SUPPORT.]
ENTER NUMBER
[RANGE=0-366]

98
99

DON’T KNOW
REFUSED

PERIOD OF SERVICE
Q32. In the following, we would like to obtain some information on your active duty military history.
Most veterans have served only one continuous tour of duty, with no breaks in service. A one time
discharge from the military after continuous service is one term of service. However, some veterans have
experienced breaks in service and thus have served multiple terms of service. How many terms of active
duty military service have you served? Please do not include Reserve or National Guard training or drill
periods unless “activated” at the time.
/IF PROXY=01/ In the following, we would like to obtain some information on ’s
active duty military history. Most veterans have served only one continuous tour of duty, with no
breaks in service. A one time discharge from the military after continuous service is one term of
service. However, some veterans have experienced breaks in service and thus have served
multiple terms of service. How many terms of active duty military service has
served? Please do not include Reserve or National Guard training or drill periods unless
“activated” at the time.
[INTERVIEWER NOTE: WE ARE ONLY RECORDING THE FIRST SIX PERIODS.]
01
98
99

ENTER NUMBER
(SKIP TO Q34) DON’T KNOW
(SKIP TO Q34) REFUSED

Q32a. /IFQ32 >1/I would like to ask you the year you started and ended each of these terms of active
duty military service. Starting with your first…
/IF Q32=1/ I would like to ask you the year you started and ended this term of active duty military
service.

VA Form 10-20134g
XXXX 2007

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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
/IF PROXY=01/I would like to ask you the year started and ended each of
these terms of active duty military service. Starting with first…
/IF PROXY=01 and Q32=1/I would like to ask you the year started and ended
this term of active duty military service.
/START LOOP EQUAL TO Q32/
Q32b_X What year did your term of active duty military service start?
/IF Q32=1/ What year did your term of active duty military service start?
/IF PROXY=01/ What year did ’s term of active duty military service
start?
/IF PROXY=01 and Q32=1/ What year did ’s term of active duty military service
start?
01

ENTER YEAR

98
99

DON’T KNOW
REFUSED

[RANGE: >=1918]

Q32c_X What year did your term of active duty military service end?
/IF Q32=1/ What year did your term of active duty military service end?
/IF PROXY=01/ What year did ’s term of active duty military service
end?
/IF PROXY=01 and Q32=1/ What year did ’s term of active duty military service
end?
01

ENTER YEAR

98
99

DON’T KNOW
REFUSED

COMBAT STATUS
Q33_X. During this term of military service were you ever in or exposed to combat?
/IF PROXY=01/ During this term of military service was ever in or exposed to
combat?
01
02

YES
NO

98
99

DON’T KNOW
REFUSED

/END LOOP/

VA Form 10-20134g
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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
EMPLOYMENT STATUS
Q34. How would you best characterize your employment status? I am going to read you a list. Please
listen to all of the choices and then tell me which best describes you. Are you
01
02
03
04
05
06

Employed Fulltime
Self-employed fulltime
Employed part-time
Self employed part-time
Unemployed, looking for work, or laid off
Currently not employed – either retired, a homemaker, student, etc.

98
99

DON’T KNOW
REFUSED

ETHNICITY AND RACE
Q35.

Would you describe yourself as Spanish, Hispanic, or Latino?
/IF PROXY=01/ Would you describe as Spanish, Hispanic, or Latino?

01
02

YES
NO

98
99

DON’T KNOW
REFUSED

Q36.

I am going to read you a list, please tell me which of the following describes your race? You can
choose more than one. Are you …
/IF PROXY=01/ I am going to read you a list, please tell me which of the following describes
’s race? You can choose more than one….
[INTERVIEWER NOTE: PLEASE READ LIST.]

/MUL=5/
01
02
03
04
05

American Indian or Alaska Native
Asian
Black or African-American
Native Hawaiian or Other Pacific Islander
White

98
99

DON’T KNOW
REFUSED

HOUSEHOLD INCOME
Q37.

Could you please tell me what your total annual household income was from all sources in 2007.
/IF PROXY=01/ Could you please tell me what was ’s total annual household
income was from all sources in 2007.
[IF NECESSARY: I would like to remind you that everything we discuss is confidential, and that
your answer to this question will not affect your benefits.]

VA Form 10-20134g
XXXX 2007

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2008 (CATI) SURVEY OF VETERAN ENROLLEES’
HEALTH AND RELIANCE UPON VA
[IF NECESSARY: Your best guess or estimate is fine.]
01

ENTER AMOUNT IN DOLLARS:

98
99

DON’T KNOW
REFUSED

[RANGE=1-999,999]

SKIP TO Q37c.

Q37a This information is critical for VA for planning purposes. Could you please tell me which of the
following best describes your 2007 total annual household income from all sources. Would you say it
is…..
/IF PROXY=01/ This information is critical for VA for planning purposes. Could you please tell me
which of the following best describes ’s 2007 total annual household income from all
sources. Would you say it is…..
(READ LIST [ROUND UP “999], THEN FOLLOW-UP AS INDICATED)
b. Is it….

a.

OR
(Do Not Read)

Less than $16,000

1→

$16,000 - $25,999,

2→

$26,000 - $35,999,

3→

$36,000 - $45,999,

4→

$46,000 - $55,999, OR

5→

$56,000 or over?
DON’T KNOW
REFUSED TO ANSWER

6
7
8

Under $11,000, or
$11,000 - $15,999?
$16,000 – $20,999
$21,000 - $25,999?
$26,000 – $30,999
$31,000 - $35,999?
$36,000 – $40,999
$41,000 - $45,999?
$46,000 – $50,999
$51,000 - $55,999?
AUTO CODE $56,000+
DON’T KNOW
REFUSED TO ANSWER

1
2
3
4
5
6
7
8
9
10
11
12
13

Q37c. Can you please tell me which state you are in?
National list of two letter abbreviations and PR for Puerto Rico?
98
99

DON’T KNOW
REFUSED

That’s all I have. Thank you for your participation. The information you have provided will help
VA to better serve all veterans in the future.

TIME ENDED______________

DATE OF INTERVIEW:
(MM/DD/YY)

VA Form 10-20134g
XXXX 2007

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