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pdfDepartment of Veterans Affairs
National Survey of Veterans (NSV)
Demobilized National Guard/Reserve Survey
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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.
A4.
Section A
Background Questions
A1. Have you ever served on active duty in the
U.S. Armed Forces?
Did you deploy in support of Operation
Enduring Freedom (OEF) or Operation Iraqi
Freedom (OIF)?
Yes
No
Yes, now on active duty
Yes, on active duty in the past, but not
now Go to Question A2
A5.
In what year did you first enter active duty?
Year
No, never on active duty except for
initial/basic training
No, never served in the U.S. Armed Forces
A6.
A1a. Thank you. This survey is intended for
Veterans of active duty service. Please return
the survey in the enclosed pre-paid return
envelope.
A2.
In what year were you last released from
active duty?
Year
A7.
In which branch or branches did you serve on
active duty? Mark all that apply.
How many times have you been activated
since becoming a member of the Reserves or
National Guard?
1 time
Army
2 times
Navy
3 or more times
Air Force
A8.
Marine Corps
Coast Guard
[NOTE: Persons serving in a combat or war
zone usually receive combat zone tax
exclusion, imminent danger pay, or hostile fire
pay.]
Other (e.g., the Public Health Service, the
Environmental Services Administration, the
National Oceanic and Atmospheric
Administration, U.S. Merchant Marine)
A3.
Did you ever serve in a combat or war zone?
Yes
No
When did you serve on active duty in the U.S.
Armed Forces? Mark all that apply.
A9.
September 2001 or later
August 1990 to August 2001 (includes
Persian Gulf War)
During your military service, were you ever
exposed to dead, dying, or wounded people?
Yes
No
May 1975 to July 1990
Vietnam era (August 1964 to April 1975)
A10. Were you ever a prisoner of war?
February 1955 to July 1964
Yes
Korean War (July 1950 to January 1955)
No
January 1947 to June 1950
World War II (December 1941 to December
1946)
November 1941 or earlier
1
A11. 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?
B2.
Below is a list of topics about VA benefits and
services. Please indicate whether you have
looked for information on these in the past
year.
Yes No
Definitely Yes
a. Eligibility for VA health care
Probably Yes
b. VA health care facility locations
Probably No
c.
Definitely No
VA life insurance
d. VA home loans
Don’t know
e. VA education and training
f.
VA vocational rehabilitation
g. VA burial and memorial benefits
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).
h. VA disability compensation and pension
i.
VA benefits for dependents and survivors
j.
VA prescription benefits
B3.
a. I thoroughly understand
the Veterans benefits that
are available to me.
b. I thoroughly understand
the Veterans health care
benefits I’m entitled to.
c. I thoroughly understand
the Veterans burial
benefits available to me.
d. I thoroughly understand
the Veterans education
and training benefits I’m
entitled to from VA.
e. I thoroughly understand
the Veterans life
insurance benefits I’m
entitled to.
f. I thoroughly understand
the Veterans Home Loan
Guaranty benefits I’m
entitled to.
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?
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 not disagree
Disagree
Strongly disagree
Section C appears on the next page.
2
B3c. How beneficial was the VA benefits portion of
the briefing?
C1a. What are the reasons you haven’t applied for
any VA disability benefits? Mark all that apply.
Very beneficial
Don’t have a service-connected disability
Somewhat beneficial
Not aware of VA service-connected disability
program
Not at all beneficial
Don’t think I’m entitled or eligible
Getting military disability pay
B3d. Was the presenter knowledgeable?
Getting disability income from another source
Very knowledgeable
Don’t think disability is severe enough
Somewhat knowledgeable
Don’t know how to apply
Not at all knowledgeable
Don’t want any assistance
Don’t need assistance
B4.
Applying is too much trouble or red tape
Did you find the transition program useful in
providing information on the Uniformed
Services Employment and Reemployment
Rights Act (USERRA)?
Never thought about it
Other Please specify below
Yes
No
B5.
Don’t know
During the VA benefits briefing, did you get a
thorough understanding of what the USERRA
provides?
QUESTION C1a SKIPS TO SECTION D
ON PAGE 6
C2.
Yes
No
Do you have a VA service-connected
disability rating?
Yes
No Go to Question C3
Section C
Disability and Vocational Rehabilitation
C1. Have you ever applied for VA disability
compensation benefits?
C2a. What is your current VA service-connected
disability rating?
0 percent
Yes Go to Question C2
10 or 20 percent
No
30 to 40 percent
50 to 60 percent
70 percent or higher
Don’t know
C2b. Has your VA service-connected disability
ever prevented you from getting or holding a
job?
Yes
No Go to Question C3
Question C3 appears on the next page.
Question C2 appears in the next column.
3
C2c. Does your VA service-connected disability
currently keep you from getting or holding a
job?
C3.
C8.
What are the reasons you have not used any
VA vocational rehabilitation services?
Mark all that apply.
Yes
Don’t have a service-connected disability
No
Didn’t think disability was severe enough
Didn’t know how to apply for or get needed
benefits
What is the status of your most recent claim
application?
Didn’t want financial assistance from VA
Approved
Didn’t need financial assistance from VA
Waiting for decision from VA regional office
Applying was too much trouble or red tape
Waiting for decision from the board of appeals
Never considered applying
Denied
Got assistance from somewhere else
Don't know
Got better/didn’t need assistance any more
Just had claim approved
C4.
Are you currently receiving regular disability
payments from VA?
Other Please specify below
Yes
No Go to Question C7
C5.
Please indicate what sort of VA disability
income you are receiving. Mark all that apply.
QUESTION C8 SKIPS TO SECTION D
ON PAGE 6
Service-connected disability compensation
Non-service-connected disability pension
C6.
C9.
During the past year, how important was the
disability payment benefit you received from
VA in helping you meet your financial needs?
Extremely important
Extremely important
Very important
Very important
Moderately important
Moderately important
Slightly important
Slightly important
Not at all important
Not at all important
Don’t know
C7.
How important were these VA vocational
rehabilitation services in helping you meet
employment goals or in helping you get a
job?
Have you ever used vocational rehabilitation
services from VA?
Yes Go to Question C9
No
Question C9 appears in the next column.
4
C10. If you are employed, what VA services were
helpful to you in obtaining a job? Mark all that
C13. If you discontinued a VA vocational
rehabilitation program, what services could
have helped you complete your program?
apply.
Mark all that apply.
Educational services
Financial support
Financial assistance
Flexible training program
Job development training
Job placement services
Job placement services
Independent living services
Not employed
Other Please specify below
Other Please specify below
QUESTION C13 SKIPS TO
SECTION D ON THE NEXT PAGE.
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.
C14. If you completed the VA vocational
rehabilitation program, what services helped
you complete your program? Mark all that
Financial benefit
apply.
Payment of tuition and books
Length of training program
Testing and evaluation
Support of VA vocational rehabilitation
counselor
Guidance and counseling
Assistance in finding employment
Medical and dental referral
Referral for medical or dental benefits
Financial support
Other Please specify below
Job placement
Training and education
Employment follow-up
Other Please specify below
C12. Why did you stop participating in the VA
vocational rehabilitation program?
Completed my program Go to Question C14
Financial barriers
Changed jobs
Medical reasons
Other Please specify below
Question C14 appears in the next column.
5
D5.
Section D
Health Status
D1.
Do you now smoke cigarettes every day,
some days, or not at all?
Every day
Some days
In general, would you say your health is…
Not at all
Excellent
No response
Very good
Good
Section E
Health Care
E1. Have you ever been enrolled in VA health
care?
Fair
Poor
D2.
Are you currently in need of the aid and
attendance of another person or are you
permanently housebound?
Yes
No
Don’t know
Yes
E2.
No
D3.
Have you ever used any VA health care
benefits?
Yes Go to Question E3
In the past week, have you required
assistance in the following activities due to
a health condition?
No
Don’t know
E2a. What are the reasons you never used any VA
health care benefits? Mark all that apply.
Did not need any care
Not aware of the VA health care benefits
Not entitled or eligible for health care benefits
a. Bathing
Do not know how to apply for health care
benefits
b. Eating
c.
Transferring from bed or a
chair
Did not need or want assistance from VA
Too much trouble or red tape
d. Using the toilet
Never considered getting any health care from
VA
e. Walking around your home
f.
Dressing
Don’t think VA health care would be as good
as that available elsewhere
g. Preparing meals
I use other sources for health care
h. Managing your money
i.
Doing household chores
j.
Using the telephone
k.
Taking medications properly
D4.
VA care is difficult to access (parking,
distance, appointment availability)
Applied, but was told that I am not eligible
Other Please specify below
Have you smoked at least 100 cigarettes in
your entire life?
Don’t know
Yes
QUESTION E2a SKIPS TO QUESTION E4
ON PAGE 8
No
Question E3 appears on the next page.
6
E3.
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?
No, no need for health care services at all
Yes – I received services at VA / VA paid for
services
No – I did not receive VA services / VA did not
pay for services
Don’t know/Don’t remember
E3a. What were the reasons you didn’t use the VA
health care services in the past six months?
Mark all that apply.
Do not need any care
Not aware of the VA health care benefits
Do not believe entitled or eligible for health
care benefits
Bad prior experience
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
Never considered getting any health care from
VA
Don’t think VA health care would be as good
as that available elsewhere
Use other sources for health care
VA care is difficult to access (parking, and/or
appointment availability)
VA care is difficult to access due to distance
I do not feel welcome at VA
VA does not provide the services that I need
Other Please specify below
Don’t know
7
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
b. Outpatient care for doctor visits,
urgent care, routine exams,
medical tests, or shots
Yes
Yes
01 = CHAMPUS, CHAMPVA,
TRICARE, or the military
No
No
02 = Medicare
c.
Yes
Yes
No
No
03 = Medigap insurance
[Medicare Supplement]
Yes
Yes
No
No
Yes
Yes
No
No
07 = Out of pocket by you or your
family
Yes
Yes
No
No
08 = Anyone else
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
8
04 = Medicaid
05 = Some other government
program
06 = Private insurance from an
employer, union, or directly
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 healthcare
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
9
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?
b. Doctor's office visits?
Indian Health Service
c.
Any other type of health insurance or health
coverage plan Please specify below
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:
F4. Does any of this insurance coverage include
prescription drug coverage?
Former employer
Individually purchased coverage
Yes
Federal, State, County, or local community
health services program
No Go to Question F6
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
Question F6 appears on the next page.
10
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 was the VA educational
assistance 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
apply.
Extremely important
During active duty service
Very important
After active duty service
Moderately important
Both during and after active duty service
Slightly important
Have never used education and training
benefits Go to Question G3
Not at all important
QUESTION G2c SKIPS TO QUESTION G4
ON THE NEXT PAGE
Question G3 appears on the next page.
11
G3. What are the reasons you haven’t used any
of the VA educational assistance? Mark all
Section H
Employment
that apply.
I used state education benefits from the
National Guard instead
Now, we have a few questions about your employment
status.
Not aware of VA education or training benefits
H1.
Don’t believe entitled or eligible for education
or training benefits
Time ran out
Don’t know how to apply for education or
training benefits
{
During the last week, were you…
Working, or on paid vacation or sick leave
from work Go to Question H2
Not working, but looking for work Go to
Question H2
Don’t need any additional education or
training
Not working and not looking for work
Don’t need or want assistance from VA
H1a. What is the main reason you were not looking
for work?
Too much trouble or red tape
Never considered getting any education or
training from VA
You are retired
Did not pay into training funds during active
duty
You stopped looking for work because you
could not find work
You are disabled
Other Please specify type below
You were temporarily laid off from work
You were taking care of your home and family
You were going to school
Other Please specify below
G4. Other than the VA assistance you noted
previously, have you received any other
education or training assistance since
discharge or separation?
H2.
Yes
No Go to Question G6
Does your most recent civilian job generally
match the occupations you were trained for
while you were in the military?
Yes
G5. What type of other education or training
assistance have you had since discharge or
separation? Please specify below
No
Have not had any civilian jobs Go to
Question H4
H3.
G6. While on active duty, did you use the
military’s tuition assistance (TA)?
How much did the training, skills or
experiences you gained in the military apply
to your most recent civilian job?
A lot
Some
Yes
A little
No
Not at all
Have not had any civilian jobs
Question H4 appears on the next page.
12
H4.
In returning from your most recent activation,
did you enroll in a Service-sponsored
program to assist you in transitioning to
civilian life?
H8.
{
Yes
No
H5.
At the time of your most recent activation,
were you enrolled in a civilian school?
{
Yes
No Go to Introduction to Question H7
Yes, different job with different employer
No, did not have a civilian job at the time I
was activated Go to Question H11
No, I did not try to return to a civilian job after
deactivation Go to Question H11
Job I went back to was similar
Part-Time (less than 12 credit hours per term)
Job I went back to was quite different
H9.
These next questions ask about past work
experience, both civilian and military, and how it
relates to your current or most recent employment.
Did you return to civilian employment
immediately following your most recent
activation?
Yes Go to Question H11
Were you employed when you were called up
for active duty?
No
Yes
H9a. Why did you not immediately return to civilian
reemployment? Mark all that apply.
No Go to Question H8
I was not employed at the time I was
activated Go to Section I
H7a. How many hours per week did you USUALLY
work at your job?
I chose not to return Go to Section I
If you have more than one job, please answer
for your main job. By ‘main job’ we mean the
one at which you usually work the most hours.
My employer did not offer me my job back
My employer did not offer me any job
My employer offered me a job I could not
accept
Hours
Question H8 appears in the next column.
Yes, previous job with earlier employer (not
employer I was working for when I was
activated) Go to Question H9
H8a. Compared with the job you had before being
called to active duty, would you say the job
you went back to was similar or quite
different?
At the time of your most recent activation,
were you a full-time student or part-time
student?
Full-Time (12 credit hours or more per term)
H7.
Yes, previous job with same employer Go
to Question H9
Yes, different job with same employer
Mark Yes if you were enrolled in the most
recent academic semester or if you were
enrolled for the next term.
H6.
We want to obtain information about your job
situation the last time you returned from
active duty. Did you return to a civilian job?
Section I appears on the next page.
Question H11 appears on the next page.
13
H10. The Uniformed Services Employment and
Reemployment Rights Act (USERRA)
prohibits discrimination against persons
because of their service in the Armed Forces,
Reserve, the National Guard, or other
uniformed services. Did you use the
Veterans' Employment and Training Service
(VETS)/Department of Labor for information
or assistance with your reemployment
problem?
Section I
Life Insurance
I1. Are you currently covered by
Servicemembers' Group Life Insurance
(SGLI)?
Yes
No
I2.
Yes
No, I sought information or assistance
elsewhere
Excluding SGLI, do you currently have life
insurance from any other source?
Yes
No, I never sought information or assistance
No Go to Question I3
H11. Have you ever filed a formal Uniformed
Services Employment and Reemployment
Rights Act (USERRA) complaint with the
Veterans' Employment and Training Service
(VETS)/Department of Labor?
I2a. If yes, how much?
Less than $10,000
$10,000 to $49,999
$50,000 to $99,999
Yes
$100,000 to $199,999
No
$200,000 to $399,999
$400,000 to $599,999
H12. In general, how supportive is your principal
civilian employer of your National
Guard/Reserve obligations?
$600,000 to $999,999
$1,000,000 or more
Very supportive
I3.
Supportive
Neither supportive nor unsupportive
Unsupportive
Very unsupportive
Were you aware that you can convert your
Servicemembers’ Group Life Insurance
(SGLI) to Veterans’ Group Life Insurance
(VGLI) after you separate from the National
Guard/Reserves?
Yes
Does not apply (not currently in civilian labor
force)
No
Does not apply to me (SGLI was not available
to me)
I4.
What is the best way for VA to communicate
insurance program changes?
Email
Direct mailings
Veterans Affairs (VA) insurance web site
(www.insurance.VA.gov)
Other
14
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
After active duty service
Both during and after active duty service
J2.
Are you aware that VA has a home loan
guaranty program for eligible Veterans?
J5.
Yes
VA loan program is offered only to U.S.
Veterans.
No
J3.
No down payment required
Have you ever obtained a home loan to
purchase a home, refinance a home loan or
make home improvements?
Convenience
No mortgage insurance required
Loan more likely to be approved
Yes
VA’s assistance to avoid foreclosure
No Go to Section K
Previous experience with the VA loan
program
J3a. When obtaining financing for your 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
J6.
No
Don’t remember
J4.
What is the most important reason you
chose to get a VA home loan?
If you have not used the VA home loan program,
what was the main reason you did not?
A conventional FHA mortgage was easier or
less expensive for me to obtain
Have you ever used the VA home loan
guaranty program?
I applied for a VA home loan, but did not
qualify
I did not apply because I did not think that I
would qualify
Yes, currently have VA home loan
Yes, not currently, but have had VA home
loan in the past
I thought that the process for obtaining a VA
loan would take too long
No, never have had VA home loan Go to
Question J6
My lender and/or realtor discouraged the use
of the VA program
The VA funding fee was too high
I didn’t know about the program
Other Please specify below
Question J6 appears in the next column.
Section K appears on the next page.
15
K3.
Section K
Burial Benefits
K1. How satisfied are you with your ability to get
accurate information about burial benefits?
Don’t
Yes No know
a. Burial at a VA National or State
Veterans cemetery
Does not apply, I have not tried to get
information
b. Headstone and burial markers
provided by VA at private
cemeteries
Very satisfied
Satisfied
c.
Neither satisfied or dissatisfied
K2.
Please indicate if you have heard about the
following burial benefits before today.
Presidential Memorial Certificates
for next of kin
Dissatisfied
d. Cash plot allowance
Very dissatisfied
e. Cash burial allowance
f.
Military Funeral Honor
g. Receiving a U.S. Flag
How important to you are the following factors
to maintaining VA National cemeteries as
shrines that honor Veterans?
Section L
Burial Plans
L1. What type of burial do you think you'll have?
a. Maintenance of the
cemetery grounds
In-ground, casket burial
b. Upkeep of headstones,
markers, and wall covers for
cremated remains
Cremation columbarium (a vault for cremated
remains)
c.
Cremation, in-ground burial
Mausoleum (i.e. tomb within a monument or
building)
Maintenance of other
landscape features
Something else
d. Appearance of committal
shelters
Don’t know
e. Appearance of individual
gravesites
f.
L2.
Maintenance of cemetery
buildings and roads
Do you want to be buried in a VA National or
State Veterans cemetery?
g. Cemetery’s front gate and
entrance area
Yes
h. Availability of parking and/or
restrooms
Don’t know
i.
Public ceremonies and
events that honor Veterans
j.
Presentation of military
funeral honors
k.
Other Please specify
below
No Go to Question L3
Question L3 appears on the next page.
16
L2a. What are your reasons for planning to be
buried in a VA National or State Veterans
cemetery? Mark all that apply.
L4.
No cost
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)?
Yes Go to Question L5
Friends or family buried there
No
Quality of services
Don’t know Go to Question L5
The honor of burial in a VA National shrine
My connection to the military/past service to
country
L4a. What are the main reasons you don’t plan to
use a headstone or marker provided by VA?
Other Please specify below
Mark all that apply.
Don’t know about headstones and markers for
Veterans
Made other arrangements
Don’t Know
Wants headstone similar to other family
members
QUESTION L2a SKIPS TO QUESTION L5
IN THE NEXT COLUMN
L3.
Don’t like VA headstones and markers
Other Please specify below
What are your main reasons for not planning
to be buried in a VA National or State
Veterans cemetery? Mark all that apply.
Don’t know eligibility criteria
Don’t know
Quality of services
Don’t know how to make arrangements with
VA
L5.
Made other arrangements
VA services don’t accommodate religious
preferences
Veterans cemetery too far away (distance)
Travel time to Veterans cemetery too long
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
Unacceptable = You would never choose this
type of burial
Appearance of cemetery doesn’t meet my
expectations
Want location close to other family members
Want services that are not available at
Veterans cemetery
a. Casket burial, in-ground
Too difficult to make arrangements with VA
b. Casket burial, in a mausoleum
Unable to make advance arrangements with
VA
c.
Cremation, ashes buried in-ground
d. Cremation, ashes placed in a
columbarium
Other Please specify below
e. Cremation, ashes scattered
f.
Don’t Know
17
Cremation, ashes kept by my family
M5. How willing are you to use the Internet for the
following activities?
Section M
Internet Use
M1. Do you use the Internet, at least
occasionally?
Yes
No Go to Question M4
a. Obtaining news and
information
M2. How often do you access the Internet or
World Wide Web?
b. Carrying out research on
services
c.
At least once a day
At least once a week but not every day
Purchasing goods or
services
d. Responding to polls or
surveys
At least once a month but less than once a
week
e. Obtain information about VA
benefits
At least once a year but less than once a
month
f.
Less than once a year
Apply for VA benefits
M6. Have you ever used the “MyHealtheVet” web
site to obtain information related to your
personal VA health care?
M3. Where do you go on-line to use the Internet?
Mark all that apply.
Home
Yes
Work
No
School
Public library
M7. Would you like to receive VA information
through the Internet or the World Wide Web?
Community center
Someone else’s house
Yes
Some other place
No
M4. Do you send or receive emails, at least
occasionally?
Yes
No Go to Question M5
M4a. Where do you go on-line to send or receive
emails? Mark all that apply.
Home
Work
School
Public library
Community center
Someone else’s house
Some other place
Question M5 appears in the next column.
18
N2.
Section N
Income
N1. Please indicate whether your family received
income (past 12 months) in any of the
categories listed below.
This includes income from all sources
mentioned in Question N1 above.
Less than $5,000
Please think about income from all members
of this family who are 15 years of age or older.
Yes
No
Which income range category represents the
total combined income of all members of this
family during the past 12 months?
$5,000 to $7,499
$7,500 to $9,999
Don’t
know
$10,000 to $12,499
a. Wages, salary, commissions,
bonuses, or tips from all jobs
$12,500 to $14,999
b. Self-employment income from
own nonfarm businesses or
farm businesses, including
proprietorships and partnerships
$20,000 to $24,999
c.
$35,000 to $39,999
$15,000 to $19,999
$25,000 to $29,999
$30,000 to $34,999
Interest, dividends, net rental
income, royalty income, or
income from estates and trusts
$40,000 to $49,999
$50,000 to $59,999
d. Social Security or Railroad
Retirement
$60,000 to $74,999
e. Supplemental Security Income
(SSI)
$75,000 to $99,999
f.
$150,000 or more
$100,000 to $149,999
Any public assistance or welfare
payments from the state or local
welfare office
g. Retirement, survivor, or
disability pensions
Section O
Demographics
O1. What is your gender?
h. Veterans’ (VA) service-connected
disability compensation payments
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
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)
19
O4. What is the highest degree or level of school
you have completed?
O6. What is your race? Mark all that apply.
White
Less than high school
Black or African American
High school diploma/GED
American Indian or Alaska Native
Some college credit, but less than 1 year of
college credit
Asian Indian
Chinese
1 or more years of college credit, no degree
Filipino
Associate’s degree (for example, AA, AS)
Other Asian (for example, Hmong, Laotian,
Thai, Pakistani, Cambodian, and so on)
Bachelor’s degree (for example, BA, BS)
Master’s degree (for example, MA, MS,
MEng, MEd, MSW, MBA)
Native Hawaiian
Guamanian or Chamorro
Professional degree beyond a bachelor’s
degree (for example, MD, DDS, DVM, LLB,
JD)
Samoan
Other Pacific Islander (for example, Fijian,
Tongan, and so on)
Doctorate degree (for example, PhD, EdD)
O7. What is your current marital status?
O5. Are you of Hispanic, Latino, or Spanish
origin?
Now married
No, not of Hispanic, Latino, or Spanish origin
Widowed
Yes, Cuban
Divorced
Yes, Mexican, Mexican American, Chicano
Separated
Yes, Puerto Rican
Never married
Yes, another Hispanic, Latino, or Spanish
origin For example: Argentinean,
Colombian, Dominican, Nicaraguan,
Salvadoran, Spaniard, and so on Please
specify below
Civil Commitment or Union
Thank you for your participation
in this very important survey.
20
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 |