Information Collection Plan for GovBenefits Online

Information Collection Plan for GovBenefits Online

OMB Control Number 1290-0003

(December 2008)

GovBenefits Questionnaire (as of December 5, 2008)

Link to GovBenefits Questionnaire.

QUESTIONS

Are you a current or former foster care recipient?

Are you a member of a demographic group whose members have been subjected to racial or ethnic prejudice?

Are you a parent or primary caregiver?

Are you a refugee who has been granted asylum?

Are you a U.S. citizen or a non-citizen with eligible immigration status?

Are you a victim of a crime that occurred during a disaster?

Are you a victim of a crime that occurred during the disaster?

Are you a victim of any of the following?(check all that apply)

Are you able and willing to start work immediately?

Are you authorized to work in the United States?

Are you blind (or partially blind)?

Are you caring for your current spouse's child who is under age 16 or disabled?

Are you caring for your former spouse's child who is under age 16 or disabled?

Are you caring for your former spouse's child who is under age 16 or disabled?

Are you currently married?

Are you currently or have you previously been employed by any of the following?(check all that apply)

Are you currently receiving or might be eligible to receive benefits from any of the following programs? (check all that apply)

Are you currently receiving or might be eligible to receive benefits from any of the following programs? (check all that apply)

Are you currently studying in any of the following grades?

Are you disabled?

Are you eligible for retirement?

Are you enrolled in a nursing school?

Are you enrolled or plan to enroll in an Advanced Placement (AP) class?

Are you in a parental or caregiving situation? If so, please describe. (check all that apply)

Are you in need of any of the following due to your current illness or injury?(check all that apply)

Are you in need of any of the following?(check all that apply)

Are you in need of assistance addressing the problems of drug-related crime in and around the premises?

Are you in need of assistance or guidance regarding any of the following? (check all that apply)

Are you incarcerated in a correctional facility?

Are you interested in any of the following? (check all that apply)

Are you interested in finding Veteran Affairs information?

Are you likely to remain in foster care?

Are you now or were you ever living with your grandparent?

Are you or a family member enrolled in a federally recognized American Indian tribe or Alaskan Native village?

Are you or a member of your household a: (select all that apply)

Are you or a member of your household enrolled in a federally recognized American Indian tribe or Alaskan native village?

Are you or a member of your household receiving government assistance?

Are you or any of your family/household members suffering from an injury or illness?

Are you pursuing a degree? If so, what degree are you pursuing?

Are you qualified/certified/licensed for any of the following?(check all that apply)

Are you receiving any form of public assistance?

Are you receiving any of the following? (check all that apply)

Are you receiving or do you need Veterans' assistance or medical care?

Are you recognized in your field for significant contributions in the following?(check all that apply)

Are you suffering from a work-related injury or disease?

Are you the dependent child of an active duty service member or member of the ready reserve of a uniformed service?

Are you the first in your family to attend college?

Are you the head of household?

Are you the spouse or surviving dependent of a veteran (living or deceased)?

Are you the spouse/or surviving dependent of a public safety officer?

Are you traveling for any of the following?(check all that apply)

Are you, or is your child, the natural child of an individual who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975?

Are your spouse, parents or children currently receiving or might be eligible to receive benefits from any of the following programs? (check all that apply)

Are your spouse, parents or children currently receiving or might be eligible to receive benefits from any of the following programs? (check all that apply)

As a result of this disaster, are you in need of assistance in any of the following categories? (select all that apply)

As part of your degree, have you completed:

At any time during the last 10 years, did you have a 6-year obligation to serve in the Reserves or National Guard?

Choose the option that best describes where you live:

Choose the option that best describes your citizenship status:

Choose the option that best describes your current spouse’s citizenship status:

Choose the option that best describes your current student status:

Choose the option that best describes your status as a non-citizen legally admitted to the U.S.:

Date of Birth?

Did the deceased veteran die in a VA hospital or while in a nursing home under VA contract?

Did the VA last notify you about your service-connected disability within the past 2 years?

Did you become the major supporter or breadwinner of a household because the breadwinner died as the direct result of a Presidentially declared major disaster?

Did you complete at least 24 continuous months of active duty service?

Did you decline the Montgomery GI Bill at your initial entry into service?

Did you ever receive support from a child who is now deceased?

Did you face significant economic or other environmental disadvantages in obtaining your education or training in health care?

Did you have a 6-year obligation to serve in the Reserves or National Guard?

Did you incur a disability or aggravate a pre-existing disability during a reserve period?

Did you join the Reserves or National Guard within the last 10 years?

Did you or a family member serve at least 90 days with at least 1 day during a period of wartime?

Did you previously receive Social Security benefits based on your former spouse's work record?

Did you previously receive Social Security benefits based on your former spouse's work record?

Did you receive a SSI payment in December 1998 or in any month in 1999?

Did you serve in the organized forces of the Philippines (or the organized guerrilla forces under the auspices of the U.S. military) between July 26, 1941 and December 30, 1946?

Did your deceased family member work as or at any of the following?(check all that apply)

Did your family member die due to a work-related injury or disease?

Did your non-compensable condition or disability result from combat wounds or service trauma?

Do any following professional situations apply to you? (check all that apply)

Do any of the following health related issues apply to you? (check all the apply)

Do you and your current spouse live together?

Do you feel that you have been denied housing or financial assistance due to discrimination?

Do you have a birth defect related to your mother's military service in Vietnam?

Do you have a child who is not covered by health insurance, including Medicaid?

Do you have a child with a birth defect related to your military service in Vietnam?

Do you have a family member who died due to any of the following?(check all that apply)

Do you have a grandparent who is deceased or is receiving Social Security benefits?

Do you have a nursing degree?

Do you have a service connected and compensable dental disability?

Do you have an educational debt that is greater than or equal to 20% of your institutional base salary?

Do you have any children that have passed away?

Do you have any necessary disaster-related expenses (property loss, medical, funeral, transportation) for which you have received no insurance or government compensation?

Do you have debt in any of the following areas? (check all that apply)

Do you have end-stage renal disease (i.e., kidney failure requiring dialysis or a scheduled or completed transplant)?

Do you live on an Indian reservation or in an Alaskan Native village?

Do you live with someone who is dependent on you for financial support?

Do you need Federal income tax information and return preparation assistance?

Do you need financial assistance for any of the following?(check all that apply)

Do you need medical advice or guidance for any of the following? (check all that apply)

Do you or any of your family/household members have any of the following conditions?(check all that apply)

Do you or are you interested in traveling outside the 50 states, Puerto Rico and the District of Columbia?

Do you or your family member have a military service-connected disability, injury, or disease?

Do you own savings bonds?

Do you speak English fluently?

Does either of your parents (including adoptive parents or stepparents) receive Social Security retirement or disability benefits?

Does your condition prevent you from any of the following?(check all that apply)

Does your current spouse receive Social Security retirement or disability benefits?

Does your school, college, or university have a substantial enrollment of minorities?

Does/did your former spouse receive retirement or disability benefits?

Does/did your former spouse receive retirement or disability benefits?

From what age have you or your family/household member had this disability?

Has your dairy product been removed from the market by a public agency because of pesticide residue in the product?

Has your home flooded as a result of this disaster?

Has your spouse ever worked and paid U.S. Social Security taxes?

Have you been accepted or are you enrolled in an accredited degree program, college or university?

Have you been denied a loan by any of the following?(check all that apply)

Have you been discharged from the military within the past 12 months for a disability incurred or aggravated in the line of duty?

Have you been reimbursed by another government agency or some other source for the funeral/burial expenses?

Have you ever had to leave your home as a result of a disaster?

Have you ever worked and paid U.S. Social Security taxes?

Have you ever worked for the U.S. government?

Have you incurred losses and costs as a result of your vessel being seized?

Have you or a family member served in any of the following areas in the military?(check all that apply)

Have you or a member of your household experienced life-changing events since this disaster? (select all that apply)

Have you run away from home or are you thinking about running away from home?

Have you suffered from discrimination based on sex and race, limited English proficiency, disability or age?

How did the marriage end?

How many are blind or disabled?

How many brothers and sisters live with you who are under age 18 or students age 18 - 21?

How many months have you been unemployed?

How many of your and your current spouse's children live with you who are under age 18 or are students age 18 - 21?

How many parents live with you?

How many people live in your household?

How many times have you been married? (0-10)

How many years ago were you discharged or released from military active duty (entering "0" indicates you were discharged or released within the last year)?

How many years of experience do you have in your current profession?

How much do you earn each month from working?

How much do you receive each month from the following sources:
U.S. or foreign Social Security benefits (do not include SSI payments)
Veterans compensation or pension (including similar benefits from foreign countries)
Railroad Retirement Board benefits
Pensions (including employer, Union, Federal, State, local, or foreign government, military pensions or disability benefits)
Black Lung benefits
Unemployment Compensation or Worker’s Compensation benefits
Insurance, annuity or Individual Retirement Account (IRA) payments
Bureau of Indian Affairs benefits
Other benefits you receive on a regular basis

How much do you spend each month for any of the following items? (include amounts that are taken out of your pay):
Federal, State and local income taxes
Social Security taxes (F.I.C.A. taxes)
Lunch
Care for a guide dog
Transportation to and from work (any transportation costs should be included)
Attendant care services
Visual and sensory aids
Translation of materials into Braille
Professional association fees
Union dues

How much do your parents earn each month from working?

How much does your current spouse earn each month from working?

How much does your current spouse spend each month for any of the following items (include amounts that are taken out of your spouse’s pay):
Federal, State and local income taxes
Social Security taxes (F.I.C.A. taxes)
Lunch
Care for a guide dog
Transportation to and from work (any transportation costs should be included)
Attendant care services
Visual and sensory aids
Translation of materials into Braille
Professional association fees
Union dues

How much income do you receive each month from any other source?

How much other income do your parents receive each month?

How much other income does your current spouse receive each month?

How would you categorize your health insurance?

How would you characterize your income?

If you are a healthcare professional, are you willing to provide primary healthcare services in an area with a shortage of health professionals?

If you are a veteran, did you serve on active duty in:(check all that apply)

If you or a family member were in the active military service, what was the discharge status of the individual? (skip if not applicable)

In how many days are you projected to be discharged or released from active military duty?

In which U.S. State do you live?

Indicate if any of your family/household members have a disability.

Indicate the ages, in years, of the children for whom you are responsible, if any. (check all that apply)

Is at least one person in your household over the age of 60?

Is either of your parents (including adoptive parents or stepparents) deceased?

Is your current spouse blind (or partially blind)?

Is your current spouse disabled?

Is your disability expected to last 12 months or end in death?

Is your former spouse deceased?

On what date (mm/dd/yyyy) did you, your parent or your spouse begin military service?

Was the deceased veteran entitled to or receiving Veterans Affairs pension or compensation?

Was this disaster a result of a terrorist act?

Was your injury or illness caused by any of the following?(check all that apply)

Were you a prisoner of the war?

Were you held as a POW for more than 90 days?

Were you in the U.S. military from September 16, 1940 through July 24, 1947?

Were you involved in any of the following during your service in the military?(check all that apply)

Were you living with your spouse at the time of his or her death?

Were you released from active service in the Armed Forces on or after April 25, 1951?

What describes your current housing / living situation? (check all that apply)

What describes your current housing / living situation? (check all that apply)

What describes your housing/living situation prior to the disaster? (select all that apply)

What field of study are you currently or intending to pursue?(check all that apply)

What is the highest level/grade of education that you have completed?

What is the reason for your current or impending unemployment?(check all that apply)

What is the total value of any cash, bank accounts, stocks or bonds that you own individually or with someone else?

What is the total value of any cash, bank accounts, stocks or bonds that your parents own?

What is your current bank balance (savings and checking combined)?

What is your current employment status?

What is your current grade point average?

What is your current military status?

What is your current spouse's date of birth?

What is your former spouse's date of birth?

What is your gender?

What is your household's annual income before taxes?

What is your level of SGLI coverage?

What is your race/ethnicity? (check all that apply)

What length of time, in years, did you or your family member serve in the military?

What level/type of teaching have you been involved in?(check all that apply)

What percentage rating is yours or your spouse's service connected disability?

What was the date of your current marriage?

What was your child's date of death?

What was your former spouse's date of death?

What was your parent's death date?

When did the benefits based on your former spouse's work stop?

When did the marriage end?

When did you become disabled?

When were you married?

Where do you live?

Which of the following (if any), describe your current and past professional experiences? (check all that apply)

Which of the following apply to your service in the railroad industry? (check all the apply)

Which of the following describe your different sources of income and the status of those sources?(check all that apply)

Which of these best describes any real property you own or control? (check all that apply) Skip question if not applicable.

The OMB number and expiration date are displayed on the GovBenefits site-

Link to GovBenefits Privacy & Terms

Note: DOL will revise the burden estimate from 2.5 minutes to 5.5 minutes and the

expiration date after OMB approves the information collection request to extend

approval for this collection of information.

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