0924e Media and News Release Questionnaire, National Disabled

OMB Number:
Respondent Burden: 20 minutes

MEDIA AND NEWS RELEASE
QUESTIONNAIRE
NATIONAL DISABLED VETERANS WINTER SPORTS CLINIC
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.

All participants must complete questions 1-15, whether or not you wish to have a news release. If you would like a news release posted
on the Clinic's website about your participation this year, you must fill out this form completely. Our Hometown News program
promotes publicity about the Clinic by posting an individual news release for every veteran who wants one on the website during the
week of the Clinic. The releases may be found at www.wintersportsclinic.va.gov. In order to prepare your news release, we must have
all needed information in advance. We cannot gather this information during the Clinic. If you have any questions, please call VA
Public Affairs at
.
NAME (Last, First, MI)

DATE OF BIRTH

E-MAIL ADDRESS

1. PLEASE CONFIRM YOUR BRANCH OF SERVICE
ARMY

AIR FORCE

MARINE CORPS

COAST GUARD

NAVY

NATIONAL GUARD

OTHER (Please specify)
2. IF YOU ARE A PEACETIME VETERAN, WHERE AND WHEN DID YOU SERVE?
3. DID YOU SERVE IN COMBAT IN ANY OF THE FOLLOWING CONFLICTS?
WWII

KOREA

VIETNAM

THE GULF WAR

AFGHANISTAN

IRAQ

OTHER (Please specify)
4. IS YOUR INJURY OR ILLNESS COMBAT
5. WHAT DID YOU DO IN THE SERVICE?
RELATED? (Resulting from actual service in combat)
YES

NO

6. ARE YOU CURRENTLY ON ACTIVE DUTY
WITH ANY BRANCH OF THE MILITARY?
YES
NO

7. HOW WERE YOU INJURED?
8. WERE YOU EVER HELD AS A POW? (If yes, where)

YES

9. ARE YOU A VIETNAM ERA (NONCOMBAT) VETERAN?

NO
YES

NO

10. UNDER WHICH GENERAL CONDITION DOES YOUR DIAGNOSIS FALL?
AMPUTEE

PARAPLEGIC

STROKE

QUADRIPLEGIC

RIGHT LEG

AK

OR

BK

OTHER NEUROLOGICAL INJURY OR DISEASE

MULTIPLE SCLEROSIS

LEFT LEG

AK

OR

BK

HIP/KNEE REPLACEMENT

BRAIN INJURY

OTHER AMPUTATION

SEVERE ARTHRITIS

VISUALLY IMPAIRED
LEGALLY BLIND

BURN INJURY
TOTALLY BLIND

OTHER DIAGNOSIS (Describe in simple language, not medical terms)
11. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
AMVETS

MOPH

PVA

DAV

VFW

AMERICAN LEGION

OTHER

12. WHAT IS YOUR PRIMARY VA MEDICAL CENTER OR MILITARY HOSPITAL (City, State)

VA FORM
APR 2010

0924e

Adobe LiveCycle Designer

13. HOW MANY PAST YEARS HAVE YOU PARTICIPATED IN THE
NATIONAL DISABLED VETERANS WINTER SPORTS CLINIC?

14. DO YOU WANT US TO PREPARE A NEWS RELEASE ABOUT YOUR
PARTICIPATION IN THIS EVENT?
YES

NO

15. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 13, PLEASE PROVIDE THE FOLLOWING INFORMATION.
REQUEST FOR AND AUTHORIZATION TO RELEASE HEALTH INFORMATION: I REQUEST AND AUTHORIZE THE DEPARTMENT OF
VETERANS AFFAIRS TO RELEASE THE HEALTH INFORMATION CONTAINED ON THIS FORM FOR VA MEDIA PURPOSES.
(See questions 4, 7, 10 and 12.)
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED ON THE CLINIC'S WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
16. YOUR QUOTE FOR THE NEW RELEASE: (This is mandatory) (All we need are a few thoughts from you telling us such things as how you feel about the
Clinic, what sports have done for your life, how many times you've attended, what you have looked forward to the most, your past experience with skiing, what you hope
to achieve, other favorite sports, etc. Just give us a few ideas, and we'll take it from there.)

SIGNATURE (You must sign here so we can comply with your wishes)

VA FORM 0924e, APR 2010, page 2

DATE SIGNED