APPENDIX B
CONSENT FORM
Date: _______________________________
CONSENT FORM
ASSURANCE
OF CONFIDENTIALITY FOR
VOLUNTEER INTERVIEW RESPONDENTS
Westat is conducting research to test materials about life insurance programs for separated service members on behalf of the Department of Veterans Affairs (VA), Veterans Benefits Administration (VBA). The research will consist of completing a short questionnaire and participating in an interview of up to 45 minutes. Your input is very important, as it will assist the VBA in providing information on VA life insurance programs.
Your participation in this research is completely voluntary. If you feel uneasy about any topic, you can refuse to answer a question or withdraw from the interview. The interview will be audiotaped and videotaped; only staff directly working on the research will have access to the recordings. All information obtained from this study will be held in the strictest confidence. The report summarizing the findings will not contain any names or identifying information.
You will be paid $75.00 cash if you take part in this 45-minute interview. The money will be paid to you at the end of the session.
If you agree to participate in this interview, please sign the following statement:
I have read this consent form and understand the proposed project.
I consent to participate in this study.
Participant:_______________________________ ________________________________
(Print name) (Signature)
Date: _______________________________
In-depth Interview Screener/Rescreener
In-depth Interview Screener/Rescreener for VGLI Project
Name (First name/Last initial): ___________________________________________________
City/town of residence: _________________________________________________________
Age: ______
Gender:
[CHECK ONE]
( ) Male
( ) Female
Branch of military served in:
[CHECK ONE]
( ) Army
( ) Navy
( ) Air Force
( ) Marines
Rank at time of separation:_________________________________________________________
Reason for separation:_____________________________________________________________
Length of service: ________________
Do you have Veterans Group Life Insurance (VGLI)?
[CHECK ONE]
( ) Yes
( ) No
( ) Don’t know
Are you:
[CHECK ONE]
( ) Married
( ) Never married
( ) Divorced or separated
( ) Widowed
( ) Living with a domestic partner
How many children under 18 are in your household? ____________
What is the last grade of school or college you had the opportunity to complete?
[CHECK ONE]
( ) Less than high school
( ) High school graduate/GED
( ) Some college
( ) 4-year college graduate
( ) Post-graduate degree
Are you:
[CHECK ALL THAT APPLY]
( ) Employed full-time
( ) Employed part-time
( ) Unemployed
( ) Retired
( ) Student
Occupation (if applicable): ___________________________________________________
Discussion Guide
Discussion Guide
Location/Date TBD
Introduction (2 minutes)
THANK RESPONDENTS FOR ATTENDING. BRIEFLY INTRODUCE SELF.
CONFIDENTIALITY GROUND RULES.
General Questions (15 minutes)
What are some reasons to have life insurance? [PROBE FOR SPECIFICS]
How important is it to you to have life insurance? Tell me about that.
Are you familiar with Veterans Group Life Insurance or VGLI?
IF YES:
What do you know about VGLI? [PROBE FOR SPECIFICS]
How did you find out about it?
Do you remember getting this folder during your separation briefing? [HOLD UP FOLDER]
Do you remember if you received any information about VGLI in the mail? [HOLD UP SAMPLE OF FOLLOW-UP MAILING MATERIALS]
Did you receive a phone call about signing up for VGLI?
Did you do anything to learn more about the program? [e.g. visit the VGLI website, call the 800 number] [IF YES, PROBE FOR SPECIFICS]
What do you think about the post-separation insurance program? [PROBE ON THE FOLLOWING ISSUES]
Benefits [PROBE FOR SPECIFICS, e.g., cost, application process, great benefit for service members]
Barriers [PROBE FOR SPECIFICS, e.g., difficult to understand, too busy, not important to me at this stage of my life]
FOR CONVERTERS:
Why did you sign up for VGLI? [PROBE FOR SPECIFICS]
FOR NON-CONVERTERS AWARE OF THE PROGRAM:
Why didn’t you sign up for VGLI?
Messages (20 minutes: 5 minutes reading/15 minutes discussion)
Now I’d like to talk with you about the information that VGLI provides separating service members about the program. Here are the materials. I’d like you to take a few minutes to read through them.
[DISTRIBUTE COPY OF THE FOLDER, ITS CONTENTS, AND SELECTED SECTIONS OF THE FOLLOW-UP MAILING MATERIALS]
I’d like you to take about [5 minutes] to read through it. As you read, I’d like you to circle anything that stands out in an interesting or good way and put a question mark by anything that’s confusing.
What were your overall impressions of the content?
Was there anything that stood out to you as being particularly interesting or useful? [PROBE FOR SPECIFICS]
What information was new to you? [PROBE FOR SPECIFICS]
Was the deadline for signing up clear? [PROBE FOR SPECIFICS]
Do the materials motivate you to sign up for VGLI? [PROBE WHY/WHY NOT]
[HANDOUT] Here are some reasons to sign up for VGLI. Please take a minute to review them all. Please tell me which are the three best reasons to sign up for VGLI. Please put a “1” next to the best reason to sign up for VGLI, a “2” next to the 2nd best reason, and a “3” next to the third best reason.
______ VGLI is cost effective. Plans start for as low as $9 a year.
______ VGLI is a benefit you have earned for service to your country.
______ VGLI is good way to protect your spouse or children in the event of your death.
______ You can purchase VGLI regardless of your current health.
______ You are only eligible to sign up for VGLI for up to 1 year after separation.
______ OTHER REASONS TAKEN FROM MATERIALS
[DISCUSS.WHY R SELECTED TOP THREE REASONS.]
Design Review (10 minutes)
What did you think about the folder and the inserts? [PROBE FOR SPECIFICS]
What did you like?
What did you dislike?
Could the folder and inserts be improved? How?
What did you think about the way the publication was written? [PROBE FOR TONE, WHETHER DIFFICULT/EASY TO READ]
Was anything in the publication confusing or not clear to you? Where did you put question marks?
Was the material well organized? Appropriate? Relevant? [PROBE FOR SPECIFICS]
Were the instructions for applying clear/easy to understand? [PROBE FOR SPECIFICS]
What did you think about the mailing materials?
What did you like?
What did you dislike?
Could the mailing materials be improved? How?
What did you think about the way it was written? [PROBE FOR TONE, WHETHER DIFFICULT/EASY TO READ]
Was anything confusing or not clear to you? Where did you put question marks?
Was the material well organized? Appropriate? Relevant? [PROBE FOR SPECIFICS]
Were the instructions for applying clear/easy to understand? [PROBE FOR SPECIFICS]
What did you think about the rate sheet?
What did you like?
What did you dislike?
Could the rate sheet be improved? How?
What did you think about the way it was written? [PROBE FOR TONE, WHETHER DIFFICULT/EASY TO READ]
Was anything confusing or not clear to you? Where did you put question marks?
Was the material well organized? Appropriate? Relevant? [PROBE FOR SPECIFICS]
Were the instructions for applying clear/easy to understand? [PROBE FOR SPECIFICS]
What did you think about the application?
What did you like?
What did you dislike?
Could the application be improved? How?
What did you think about the way it was written? [PROBE FOR TONE, WHETHER DIFFICULT/EASY TO READ]
Was anything confusing or not clear to you? Where did you put question marks?
Was the material well organized? Appropriate? Relevant? [PROBE FOR SPECIFICS]
Were the instructions for applying clear/easy to understand? [PROBE FOR SPECIFICS]
PLEASE RETURN THIS QUESTIONNAIRE TO YOUR HOST OR HOSTESS.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |