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pdfDepartment of Veterans Affairs
National Survey of Veterans (NSV)
Veteran Survey
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this form, please write to: VA, xxxx
If you have any questions or concerns, please call the NSV Survey Helpline at 1-888-NSV-2009 or send an
email to [email protected]
Instructions to Complete the Survey
To answer a question, simply check the box that best represents your answer.
You will sometimes be asked to skip questions based on your answers. In addition, certain
sections of the questionnaire may not apply to you.
Please choose only one answer per question, unless the question indicates Mark all that
apply.
A3.
Section A
Background Questions
A1. Have you ever served on active duty in the
U.S. Armed Forces?
When did you serve on active duty in the U.S.
Armed Forces? Mark all that apply.
September 2001 or later
August 1990 to August 2001 (includes
Persian Gulf War)
Yes, now on active duty
May 1975 to July 1990
Yes, on active duty in the past, but not
now Go to Question A1b
Vietnam era (August 1964 to April 1975)
No, never on active duty except for
initial/basic training
February 1955 to July 1964
No, never served in the U.S. Armed Forces
January 1947 to June 1950
Korean War (July 1950 to January 1955)
World War II (December 1941 to December
1946)
A1a. Thank you. This survey is intended for
Veterans of active duty service. Please return
the survey in the enclosed pre-paid return
envelope.
November 1941 or earlier
A4.
A1b. Was any of this active duty service part of a
mobilization or activation while serving as a
member of the National Guard or Reserve
Component?
Did you deploy in support of Operation
Enduring Freedom (OEF) or Operation Iraqi
Freedom (OIF)?
Yes
No
Never served on active duty as a member of
the National Guard/Reserve Component
A5.
Yes, served on active duty while in the
National Guard/Reserves (and I am still
serving in the National Guard/Reserves)
In what year did you first enter active duty?
Year
Yes, served on active duty while in the
National Guard/Reserves (and have
separated/retired from the National
Guard/Reserves)
A6.
In what year were you last released from
active duty?
Year
A2.
In which branch or branches did you serve on
active duty? Mark all that apply.
A7.
Army
Did you ever serve in a combat or war zone?
[NOTE: Persons serving in a combat or war
zone usually receive combat zone tax
exclusion, imminent danger pay, or hostile
fire pay.]
Navy
Air Force
Marine Corps
Yes
Coast Guard
No
Other (e.g., the Public Health Service, the
Environmental Services Administration, the
National Oceanic and Atmospheric
Administration, U.S. Merchant Marine)
A8.
During your military service, were you ever
exposed to dead, dying, or wounded people?
Yes
No
1
A9.
Were you ever a prisoner of war?
B2.
Yes
No
Below is a list of topics about Veteran’s
benefits and services. Please indicate
whether you have looked for information on
these in the past 12 months.
Yes No
A10. During your military service, were you ever
exposed to environmental hazards such as
Agent Orange, chemical warfare agents,
ionizing radiation, or other potentially toxic
substances?
a. Eligibility for VA health care
b. Locating a VA health care facility (such as
a VA hospital or medical center)
c.
VA life insurance
d. VA home loans
Definitely Yes
e. VA education and training
Probably Yes
f.
Probably No
VA vocational rehabilitation
g. VA burial and memorial benefits
Definitely No
h. VA disability compensation and pension
Don’t know
Section B
Familiarity With Veteran Benefits
B1. Please indicate how much you agree or
disagree with the following statements regarding
the Veterans benefits provided by Department of
Veterans Affairs (VA).
i.
VA benefits for dependents and survivors
j.
VA transition assistance
k.
VA prescription benefits
B3.
While you were on active duty, did you attend
any of the transition assistance workshops
known as the Transition Assistance Program
(TAP) or the Disabled Transition Assistance
Program (DTAP)?
Yes
No Go to Section C
B3a. How useful did you find the transition
program in providing information about VA
benefits and services?
a. I thoroughly understand
the Veteran’s benefits
that are available to me.
b. I thoroughly understand
the Veteran’s health care
benefits I’m entitled to.
c. I thoroughly understand
the Veteran’s burial
benefits available to me.
d. I thoroughly understand
the Veteran’s education
and training benefits I’m
entitled to from VA.
e. I thoroughly understand
the Veteran’s life
insurance benefits I’m
entitled to.
f. I thoroughly understand
the Veterans Home Loan
Guaranty benefits I’m
entitled to.
Very useful
Useful
Somewhat useful
Not useful
B3b. Please indicate how much you agree or
disagree with the following statement.
I have a thorough understanding of what VA
benefits are available based on the VA
benefits briefing.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Section C appears on the next page.
2
B3c. How beneficial was the VA benefits portion of
the briefing?
C2.
Do you have a VA service-connected
disability rating?
Very beneficial
Yes
Somewhat beneficial
No Go to Question C3
Not at all beneficial
C2a. What is your current VA service-connected
disability rating?
B3d. Was the VA benefits presenter
knowledgeable on the subject?
0 percent
Very knowledgeable
10 or 20 percent
Somewhat knowledgeable
30 to 40 percent
Not at all knowledgeable
50 to 60 percent
70 percent or higher
Don’t know
Section C
Disability and Vocational Rehabilitation
C1. Have you ever applied for VA disability
compensation benefits?
C2b. Has your VA service-connected disability ever
prevented you from getting or holding a job?
Yes
Yes Go to Question C2
No Go to Question C3
No
C2c. Does your VA service-connected disability
currently keep you from getting or holding a
job?
C1a. What are the reasons you haven’t applied for
any VA disability benefits? Mark all that apply.
Don’t have a service-connected disability
Yes
Not aware of VA service-connected disability
program
No
Don’t think I’m entitled or eligible
C3.
Getting military disability pay
Getting disability income from another source
What is the status of your most recent claim
application?
Approved
Don’t think disability is severe enough
Waiting for decision from VA regional office
Don’t know how to apply
Waiting for decision from the board of appeals
Don’t want any assistance
Don’t need assistance
Denied
Applying is too much trouble or red tape
Don't know
Never thought about it
Other Please specify below
C4.
Are you currently receiving monthly disability
payments from VA?
Yes
No Go to Question C7
Don’t know
QUESTION C1a SKIPS TO SECTION D
ON PAGE 5
C5.
Please indicate what sort of VA disability
income you are receiving. Mark all that apply.
Service-connected disability compensation
Non-service-connected disability pension
Question C7 appears on the next page.
Question C2 appears in the next column.
3
C6.
During the past year, how important was the
disability payment benefit you received from VA
in helping you meet your financial needs?
C10. If you are employed, what VA services were
helpful to you in obtaining a job? Mark all that
apply.
Extremely important
Educational services
Very important
Financial assistance
Moderately important
Job development training
Slightly important
Job placement services
Not at all important
Don’t know
C7.
Not employed
Other Please specify below
Have you ever used vocational rehabilitation
services from VA?
Yes Go to Question C9
C11. If you used VA vocational rehabilitation
benefits but were also eligible for GI Bill
benefits, why did you choose VA vocational
rehabilitation services? Mark all that apply.
No
C8.
What are the reasons you have not used any
VA vocational rehabilitation services? Mark all
Financial benefit
that apply.
Don’t have a service-connected disability
Payment of tuition and books
Didn’t think disability was severe enough
Length of training program
Didn’t know how to apply for or get needed
benefits
Support of VA vocational rehabilitation
counselor
Didn’t want financial assistance from VA
Assistance in finding employment
Didn’t need financial assistance from VA
Referral for medical or dental benefits
Applying was too much trouble or red tape
Other Please specify below
Never considered applying
Got assistance from somewhere else
Got better/didn’t need assistance any more
C12. Why did you stop participating in the VA
vocational rehabilitation program?
Just had claim approved
Other Please specify below
Not applicable—I am still in the program
Go to Section D
Completed my program Go to Question C14
Financial barriers
QUESTION C8 SKIPS TO SECTION D
ON PAGE 5
C9.
Changed jobs
Medical reasons
How important were these VA vocational
rehabilitation services in helping you meet
employment goals or in helping you get a job?
Other Please specify below
Extremely important
Very important
Moderately important
Slightly important
Not at all important
Question C14 appears on the next page.
Section D appears in the next column.
4
C13. If you discontinued a VA vocational rehabilitation
program, what services could have helped you
complete your program? Mark all that apply.
D3.
In the past week, have you required
assistance in the following activities due to
a health condition?
Financial support
Flexible training program
Job placement services
Independent living services
Other Please specify below
a. Bathing
b. Eating
c.
QUESTION C13 SKIPS TO
SECTION D BELOW
Transferring from bed or a
chair
d. Using the toilet
C14. If you completed the VA vocational
rehabilitation program, what services helped
you complete your program? Mark all that
e. Walking around your home
f.
apply.
Dressing
g. Preparing meals
Testing and evaluation
h. Managing your money
Guidance and counseling
Training and education
i.
Doing household chores
Medical and dental referral
j.
Using the telephone
k.
Taking medications properly
Financial support
Job placement
Employment follow-up
D4.
Other Please specify below
Are you currently in need of the aid and
attendance of another person or are you
permanently housebound?
Yes
No
Section D
Health Status
D1. In general, would you say your health is…
D5.
Have you smoked at least 100 cigarettes in
your entire life?
Yes
Excellent
No
Very good
Good
D6.
Fair
Poor
Do you now smoke cigarettes every day,
some days, or not at all?
Every day
D2.
How would you rate the health of your teeth
and gums? Would you say it is…
Some days
Not at all
No response
Excellent
Very good
Good
Fair
Poor
5
E3.
Section E
Health Care
E1. Have you ever been enrolled in VA health
care?
No, no need for health care services at all
Yes – I received services at VA / VA paid for
services
Yes
No
No – I did not receive VA services / VA did not
pay for services
Don’t know
E2.
In the last 6 months, did you use any VA
health care services, or did you have any of
your health care paid for by VA?
Don’t know/Don’t remember
Have you ever used any VA health care
benefits?
E3a. What were the reasons you didn’t use the VA
health care services in the past six months?
Yes Go to Question E3
No
Mark all that apply.
Don’t know
Do not need any care
Not aware of the VA health care benefits
E2a. What are the reasons you never used any VA
health care benefits? Mark all that apply.
Do not believe self entitled or eligible for
health care benefits
Did not need any care
Bad prior experience
Not aware of VA health care benefits
Do not know how to apply for health care
benefits
Not entitled or eligible for health care benefits
Do not know how to apply for health care
benefits
Do not need or want assistance from VA
Applying for health care benefits too much
trouble or red tape
Did not need or want assistance from VA
Too much trouble or red tape
Never considered getting any health care from
VA
Never considered getting any health care from
VA
Don’t think VA health care would be as good
as that available elsewhere
Don’t think VA health care would be as good
as that available elsewhere
Uses other sources for health care
I use other sources for health care
VA care is difficult to access (parking and/or
appointment availability)
VA care is difficult to access (parking,
distance, appointment availability)
VA care is difficult to access due to distance
Applied, but was told that I am not eligible
I do not feel welcome at VA
Other Please specify below
VA does not provide the services that I need
Other Please specify below
Don’t know
Don’t know
QUESTION E2a SKIPS TO QUESTION E4
ON THE NEXT PAGE
Question E3 appears in the next column.
6
E4.
Please tell us whether you have used any of the following health services for yourself in the last six
months?
Service
From VA or
paid for by
VA?
From any
other
source?
Select the one source that provides the largest
financial support, if there are multiple sources.
Source (enter number from list):
a. Overnight stay in a hospital for
medical or surgical care
Yes
Yes
No
No
01 = CHAMPUS, CHAMPVA,
TRICARE, or the military
b. Outpatient care for doctor visits,
urgent care, routine exams,
medical tests, or shots
Yes
Yes
02 = Medicare
No
No
c.
03 = Medigap insurance
[Medicare Supplement]
Yes
Yes
04 = Medicaid
No
No
05 = Some other government
program
Yes
Yes
No
No
06 = Private insurance from an
employer, union, or directly
Yes
Yes
07 = Out of pocket by you or your
family
No
No
08 = Anyone else
Yes
Yes
No
No
Yes
Yes
No
No
h. Care for any prosthetics or
medical equipment, including
home oxygen
Yes
Yes
No
No
i.
Care for hearing aids or eye
glasses
Yes
Yes
No
No
Overnight stay in a rehabilitation
hospital or nursing care facility
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
Overnight stay in a hospital for
mental health or substance
abuse treatment
d. Outpatient visits for
psychological counseling,
therapy or mental health, or
substance abuse treatment
e. Prescription medications
f.
Over the counter medications
g. In-home health care for yourself
j.
k.
Dental care
l.
Emergency Room
m. Other types of medical
treatment
Please specify below
7
E5.
WOMEN ONLY:
E6. During the past 12 months, have you used
women's health care services, for example,
for pap smears or prenatal care?
How much do you agree or disagree with the
following statements?
Yes
No Go to Question E8
a. If the cost of health care to
me increases, I will use VA
more.
E7.
b. I would only use VA if I did
not have access to any other
source of health care.
c.
During the past 12 months, have you
received women's health care services at any
of the following?
Yes No
I have a doctor outside VA
who I really like and trust.
a. A primary care clinic at a VA facility
d. Veterans who can afford to
use other sources of health
care should leave VA to
those who really need it.
b. A women’s health clinic or
gynecology clinic at a VA facility
e. Veterans like me who use
VA are satisfied with the
health care they receive.
d. A primary care provider or facility
outside VA
f.
c.
A provider or facility outside VA,
but paid for by VA
e. A women's healthcare provider or
gynecology clinic outside VA
VA health care providers
explain treatment/diagnoses
in a way that patients can
understand.
MEN AND WOMEN:
E8. If you needed long-term nursing home care,
would you:
g. There is a VA provider in my
area that offers all of the
health care services that
Veterans like me need.
Definitely go to VA
Maybe go to VA
h. I have one particular health
care provider who is in
charge of my care.
Definitely go somewhere else
E9.
What is the primary way you plan to use VA
health care in the future?
As your primary source of health care
WOMEN ARE ASKED TO ANSWER
QUESTIONS E6 and E7
Backup to non-VA care for some minor
services
MEN ARE ASKED TO SKIP TO QUESTION E8
A “safety net” to use only if needed
For prescriptions
For specialized care
Some other way
No plans to use VA for health care
8
Section F
Health Insurance
F1. Are you CURRENTLY covered by any of the
following types of health insurance or health
coverage plans? Mark all that apply.
THOSE ON MEDICARE ARE ASKED TO ANSWER
QUESTIONS F2 – F3
ALL OTHERS PLEASE SKIP TO
QUESTION F4 BELOW
Insurance through a current or former
employer or union (of yours or another family
member)
MEDICARE RECIPIENTS:
Insurance purchased directly from an
insurance company (by you or another family
member)
F2.
Medicare, for people 65 and older, or people
with certain disabilities
Did you choose to receive your Medicare
coverage through a Medicare Advantage
Plan and not through the original Medicare
Plan?
Yes
Medicaid, Medical Assistance, or any kind of
government-assistance plan for those with low
incomes or a disability
No
F2a. Does your Medicare coverage pay for…
VA (including those who have ever used or
enrolled for VA health care)
Yes No
TRICARE, TRICARE for Life or other military
health care
a. Care if you are hospitalized?
Indian Health Service
b. Doctor's office visits?
Any other type of health insurance or health
coverage plan Please specify below
c.
F3.
Prescription drug coverage, "Part D"?
Do you purchase any private health care
coverage to supplement Medicare; that is to
pay for services Medicare does not pay for?
Yes
No
F1a. Who provides this coverage? Mark all that
apply.
Current employer, including COBRA coverage
ALL RESPONDENTS:
Former employer
F4.
Individually purchased coverage
Federal, State, County, or local community
health services program
Does any of this insurance coverage include
prescription drug coverage?
Yes
No
Family member, such as a spouse, parent,
etc.
F5.
Or from somewhere else? Please specify
below
Do you currently have prescription drug
coverage from VA?
Yes
No
Don’t know
9
F6.
How much do you agree or disagree with the
following statements?
G2a. How did you use the VA education benefit?
Mark all that apply.
Took college or university coursework leading
to a bachelor or graduate degree
Attended business, technical or vocational
school training leading to a certificate or
diploma
a. I feel I know what is
available to me through my
VA health coverage.
Participated in an apprenticeship or on-job
training program
b. My family has a health
insurance plan that
adequately covers me and
my family.
Took correspondence courses
Took flight training
Received tutorial assistance, refresher
courses, or deficiency training
Attended a teacher certification program
Did something else Please specify below
Section G
Education and Training
These next few questions ask about your experience
with education and training benefits provided by the
Department of Veterans Affairs. This does not include
tuition assistance (TA) you may have received while
on active duty.
G2b. Did you complete your training, or receive the
primary degree or certificate for which you
were enrolled and receiving VA education
benefits?
G1. Excluding VA vocational rehabilitation, have
you used any other VA education or training
benefits?
Yes
No
Yes
No Go to Question G3
G2c. How important were your VA education
benefits in helping you meet your educational
goals or preparing you to get a better job?
G2. Please indicate when you used the VA
education and training benefits. Mark all that
Extremely important
apply.
During active duty service
Very important
After active duty service
Moderately important
Both during and after active duty service
Slightly important
Not at all important
Have never used education and training
benefits Go to Question G3
QUESTION G2c SKIPS TO QUESTION G4
ON THE NEXT PAGE
Question G3 appears on the next page.
10
G3. What are the reasons you haven’t used any
of the VA educational assistance? Mark all
Section H
Employment
H1. During the last week, were you…
that apply.
I used state education benefits from the
National Guard instead
{
Not aware of VA education or training benefits
Don’t believe entitled or eligible for education
or training benefits
Working, or on paid vacation or sick leave
from work Go to Question H2
Not working, but looking for work Go to
Question H2
Not working and not looking for work
Time ran out
Don’t know how to apply for education or
training benefits
H1a. What is the main reason you were not looking for
work?
Don’t need any additional education or
training
You are retired
Don’t need or want assistance from VA
You are disabled
Too much trouble or red tape
You stopped looking for work because you
could not find work
Never considered getting any education or
training from VA
You were temporarily laid off from work
Didn’t pay into training funds during active
duty
You were taking care of your home and family
Other Please specify type below
Other Please specify below
You were going to school
G4. Other than the VA assistance you noted
previously, have you received any other
education or training assistance since
discharge or separation?
H2.
Does your most recent civilian job generally
match the occupations you were trained for
while you were in the military?
Yes
Yes
No
No Go to Question G6
Have not had any civilian jobs Go to
Question H4
G5. What type of other education or training
assistance have you had since discharge or
separation? Please specify below
H3.
How much did the training, skills or
experiences you gained in the military apply
to your most recent civilian job?
A lot
Some
A little
G6. While on active duty, did you use the
military’s tuition assistance (TA)?
Not at all
Yes
No
Question H4 appears on the next page.
11
H4.
H5.
When you left the Service, how well prepared
were you to enter the civilian job market?
I1b. What are the reasons you don’t have VA life
insurance coverage? Mark all that apply.
Very well prepared
Not aware of VA insurance benefits
Well prepared
Not entitled or eligible
Neither well nor poorly prepared
Don’t know how to apply for benefits
Poorly prepared
Don’t need any insurance
Very poorly prepared
Don’t need or want assistance from VA
Not applicable; I was not interested in entering
the civilian job market
Too much trouble or red tape
Never considered getting any insurance from VA
Elected to forgo coverage while on active duty
To what extent do you agree with the
following statements?
Never converted active duty life insurance
policy to Veteran’s policy
Allowed policy to lapse
Other Please specify below
a. The military allowed me
enough time to prepare
for my transition and job
search.
b. My chain of command
was supportive when I
began transition
processing.
I2.
Excluding a VA life insurance policy, do you
currently have life insurance from any other
sources?
Yes
No Go to Question I3
I2a. If yes, how much?
Section I
Life Insurance
I1. Are you currently covered by VA life
insurance (e.g., Veterans' Group Life
Insurance/VGLI, Service-Disabled Veterans'
Insurance/SDVI)?
Less than $10,000
$10,000 to $49,999
$50,000 to $99,999
$100,000 to $199,999
Yes, covered by VGLI
$200,000 to $399,999
Yes, covered by SDVI Go to Question I2
$400,000 to $599,999
No, not covered by VA life insurance Go to
Question I1b
$600,000 to $999,999
$1,000,000 or more
I1a. What is the best way for VA to
communicate VGLI program changes?
I3.
Email
Direct mailings
Were you aware that you could have converted
your Servicemembers’ Life Insurance SGLI to
VGLI after you were discharged from service?
Veterans Affairs (VA) insurance web site
(www.insurance.VA.gov)
Yes
Other
Does not apply to me (SGLI was not available
to me)
No
QUESTION I1a SKIPS TO QUESTION I2
IN THE NEXT COLUMN
Does not apply to me (I did not have SGLI
while on active duty)
Question I1b appears in the next column.
Question I2 appears in the next column.
12
J4a. How long ago did you obtain your most
recent home loan?
Section J
Home Loans
J1. What would you say your current living
arrangement is?
Within last 5 years
6-10 years ago
11-20 years ago
Rent my home
More than 20 years ago
Own my home—with an outstanding
mortgage
J4b. When did you use the VA home loan
guaranty program?
Own my home—no mortgage balance
Occupy dwelling with no payment of cash rent
During active duty service
Other
J2.
After active duty service
Both during and after active duty service
Are you aware that VA has a home loan
guaranty program for eligible Veterans?
J5.
Yes
No
J3.
VA loan program is offered only to U.S.
Veterans
Have you ever obtained a home loan to
purchase a home, refinance a home loan or
make home improvements?
No down payment required
Convenience
Yes
No mortgage insurance required
No Go to Section K
Loan more likely to be approved
VA’s assistance to avoid foreclosure
Previous experience with the VA loan
program
J3a. When obtaining financing for this loan, did
your lender discuss VA's home loan guaranty
program with you as a possible option?
QUESTION J5 SKIPS TO SECTION K
ON THE NEXT PAGE
Yes
No
Don’t remember
J4.
What is the most important reason you
chose to get a VA home loan?
Have you ever used the VA home loan
guaranty program?
Yes, currently have VA home loan
Yes, not currently, but have had VA home
loan in the past
No, never have had VA home loan Go to
Question J6
Questions J6 appears on the next page.
Section K appears on the next page.
13
J6.
If you have not used the VA home loan
program, what was the main reason you did
not?
K2.
How important to you are the following factors
to maintaining VA National cemeteries as
shrines that honor Veterans?
A conventional FHA mortgage was easier or
less expensive for me to obtain
I applied for a VA home loan, but did not
qualify
a. Maintenance of cemetery
grounds
I did not apply because I did not think that I
would qualify
b. Upkeep of headstones,
markers, and wall covers for
cremated remains
I thought that the process for obtaining a VA
loan would take too long
My lender and/or realtor discouraged the use
of the VA program
c.
The VA funding fee was too high
d. Appearance of committal
shelters
I didn’t know about the program
Maintenance of other
landscape features
e. Appearance of individual
gravesites
Other Please specify below
f.
Maintenance of cemetery
buildings and roads
g. Cemetery’s front gate and
entrance area
h. Availability of parking and/or
restrooms
Section K
Burial Benefits
K1.
How satisfied are you with your ability to get
accurate information about burial benefits?
i.
Public ceremonies and
events that honor Veterans
j.
Presentation of military
funeral honors
k.
Other Please specify
below
Does not apply, I have not tried to get
information
Very satisfied
Satisfied
K3.
Neither satisfied or dissatisfied
Dissatisfied
Please indicate if you have heard about the
following burial benefits before today.
Don’t
Yes No know
Very dissatisfied
a. Burial at a VA National or State
Veterans cemetery
b. Headstone and burial markers
provided by VA at private
cemeteries
c.
Presidential Memorial Certificates
for next of kin
d. Cash plot allowance
e. Cash burial allowance
f.
Military Funeral Honors
g. Receiving a U.S. Flag
14
L3.
Section L
Burial Plans
L1.
Don’t know eligibility criteria
What type of burial do you think you'll have?
Quality of services
In-ground, casket burial
Cremation, in-ground burial
Don’t know how to make arrangements with
VA
Cremation columbarium (a vault for cremated
remains)
Made other arrangements
VA services don’t accommodate religious
preferences
Mausoleum (i.e. tomb within a monument or
building)
Veterans cemetery too far away (distance)
Something else
Travel time to Veterans cemetery too long
Don’t know
L2.
What are your main reasons for not planning
to be buried in a VA National or State
Veterans cemetery? Mark all that apply.
Appearance of cemetery doesn’t meet my
expectations
Do you want to be buried in a VA National or
State Veterans cemetery?
Want location close to other family members
Yes
Want services that are not available at
Veterans cemetery
No Go to Question L3
Too difficult to make arrangements with VA
Don’t know
Unable to make advance arrangements with
VA
L2a. What are your reasons for wanting to be
buried in a VA National or State Veterans
cemetery? Mark all that apply.
Other Please specify below
No cost
Friends or family buried there
Don’t Know
Quality of services
The honor of burial in a VA National shrine
L4.
My spouse’s connection to the military/past
service to country
Other Please specify below
If you choose to be buried in a private
cemetery, do you think you'll have your burial
place marked by a headstone or marker
provided by VA (at no cost to you)?
Yes Go to Question L5
No
Don’t know Go to Question L5
Don’t Know
QUESTION L2a SKIPS TO QUESTION L5
ON THE NEXT PAGE
Question L3 appears in the next column.
Question L5 appears on the next page.
15
L4a. What are the main reasons you don’t plan to
use a headstone or marker provided by VA?
Section M
Internet Use
Mark all that apply.
Don’t know about headstones and markers for
Veterans
M1. Do you use the Internet, at least
occasionally?
Made other arrangements
Yes
Wants headstone similar to other family
members
No Go to Question M4
Doesn’t like VA headstones and markers
M2. How often do you access the Internet or
World Wide Web?
Other Please specify below
At least once a day
At least once a week but not every day
At least once a month but less than once a
week
Don’t know
L5.
At least once a year but less than once a
month
For each of the burial options listed below,
please tell us if you consider the option
preferable, acceptable, or unacceptable.
Preferable
= Your first choice (choose one)
Acceptable
= Not your first choice, but would
be OK
Less than once a year
M3. Where do you go on-line to use the Internet?
Mark all that apply.
Home
Unacceptable = You would never choose this
type of burial
Work
School
Public library
Community center
Someone else’s house
a. Casket burial, in-ground
Some other place
b. Casket burial, in a mausoleum
c.
Cremation, ashes buried in-ground
M4. Do you send or receive emails, at least
occasionally?
d. Cremation, ashes placed in a
columbarium
Yes
e. Cremation, ashes scattered
f.
No Go to Question M5
Cremation, ashes kept by my family
Question M5 appears on the next page.
16
M4a. Where do you go on-line to send or receive
emails? Mark all that apply.
Section N
Income
Home
Work
N1.
School
Public Library
Please indicate whether your family received
income (past 12 months) in any of the
categories listed below.
Please think about income from all members
of this family who are 15 years of age or older.
Community Center
Someone else’s house
Some other place
Yes
a. Wages, salary, commissions,
bonuses, or tips from all jobs
M5. How willing are you to use the Internet for the
following activities?
b. Self-employment income from
own nonfarm businesses or
farm businesses, including
proprietorships and partnerships
c.
a. Obtaining news and
information
b. Carrying out research on
services
c.
d. Social Security or Railroad
Retirement
Purchasing goods or
services
e. Supplemental Security Income
(SSI)
d. Responding to polls or
surveys
f.
e. Obtain information about VA
benefits
f.
Interest, dividends, net rental
income, royalty income, or
income from estates and trusts
Any public assistance or welfare
payments from the state or local
welfare office
g. Retirement, survivor, or
disability pensions
Apply for VA benefits
h. Veterans’ (VA) service-connected
disability compensation payments
M6. Have you ever used the “MyHealtheVet” web
site to obtain information related to your
personal VA health care?
Yes
No
M7. Would you like to receive VA information
through the Internet or the World Wide Web?
Yes
No
17
i.
All other VA payments
(e.g., VA education payments)
j.
Any other sources of income
received regularly such as
unemployment compensation,
child support or alimony
No
Don’t
know
N2.
Which income range category represents the
total combined income of all members of this
family during the past 12 months?
O4. What is the highest degree or level of school
you have completed?
Less than high school
This includes income from all sources
mentioned in Question N1 above.
High school diploma / GED
Less than $5,000
Some college credit, but less than 1 year of
college credit
$5,000 to $7,499
1 or more years of college credit, no degree
$7,500 to $9,999
Associate’s degree (for example, AA, AS)
$10,000 to $12,499
Bachelor’s degree (for example, BA, BS)
$12,500 to $14,999
Master’s degree (for example, MA, MS,
MEng, MEd, MSW, MBA)
$15,000 to $19,999
Professional degree beyond a bachelor’s
degree (for example, MD, DDS, DVM, LLB,
JD)
$20,000 to $24,999
$25,000 to $29,999
$30,000 to $34,999
Doctorate degree (for example, PhD, EdD)
$35,000 to $39,999
$40,000 to $49,999
O5. Are you of Hispanic, Latino, or Spanish
origin?
$50,000 to $59,999
$60,000 to $74,999
No, not of Hispanic, Latino, or Spanish origin
$75,000 to $99,999
Yes, Cuban
$100,000 to $149,999
Yes, Mexican, Mexican American, Chicano
$150,000 or more
Yes, Puerto Rican
Yes, another Hispanic, Latino, or Spanish
origin For example: Argentinean,
Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on Please
specify below
Section O
Demographics
O1. What is your gender?
Male
Female
O2. What is your year of birth?
Year
O3. Please indicate the number of dependent
children you have.
Number of minor children
(age 17 and younger)
Number of adult children attending
High School and/or College (age 18-22)
18
O6. What is your race? Mark all that apply.
O8. At which of the following types of addresses
does your household receive mail? Mark all
White
that apply.
Black or African American
A street address with a house or building
number
American Indian or Alaska Native
Asian Indian
An address with a rural route number
Chinese
A U.S. Post Office Box
Filipino
A commercial mailbox establishment
Other Asian (for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on)
O9. At how many different addresses do you
receive your personal mail?
Native Hawaiian
Guamanian or Chamorro
Number
Samoan
Other Pacific Islander (for example, Fijian,
Tongan, and so on)
O7. What is your current marital status?
Now Married
Widowed
Divorced
Separated
Never Married
Civil Commitment or Union
Thank you for your participation
in this very important survey.
19
If found please return to:
Westat
1600 Research Blvd, RA 1136
Rockville, MD 20850
| File Type | application/pdf |
| File Title | Contract GS-23F-8144H |
| File Modified | 2009-04-06 |
| File Created | 2009-04-02 |