Information Collection Plan for GovBenefits Online

Information Collection Plan for Benefits.gov Online

OMB Control Number 1290-0003

(September 2011)

Benefits.gov Questionnaire (as of September 21, 2011)

Link to Benefits.gov Questionnaire

QUESTIONS

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

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

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

How did the marriage end?

Is your former spouse deceased?

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

What is your former spouse's date of birth? (Enter date in mm/dd/yyyy format.)

What was your former spouse's date of death? (Enter date in mm/dd/yyyy format.)

When did the benefits based on your former spouse's work stop? (Enter date in mm/dd/yyyy format.)

When did the marriage end? (Enter date in mm/dd/yyyy format.)

When were you married? (Enter date in mm/dd/yyyy format.)

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 victim of a crime that occurred during a disaster?

Are you a victim of a crime that occurred during the disaster or in the period immediately following a 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 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 know that you 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 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 or around your residence?

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

Are you interested in finding Veteran Affairs information?

Are you interested in information or guidance within any of the following? (Check all that apply.)

Are you likely to remain in foster care?

Are you now, or were you ever, living with one of your grandparents?

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 Alaska Native Tribe?

Are you or a member of your household receiving government assistance or benefits (for example, Housing Choice Voucher Program (Section 8) assistance, Social Security benefits, etc.)?

Are you or one of your direct dependents a U.S. citizen or a non-citizen with eligible immigration status?

Are you pursuing a degree or enrolled in an academic fellowship? If so, what type?

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 servicemember 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 the household in which you live?

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

Are you the spouse, child or parent of someone who is serving or has served in the military?

Are you the surviving spouse, child, or parent of a deceased veteran?

Are you, or is your child, the biological 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.)

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

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 the time of the disaster, of what state, territory, or tribal land were you a primary, legal resident?

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.:

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

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

Did you become the major supporter or breadwinner of a household because the breadwinner died as the direct result of a presidentially-declared 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 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.)

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 non-compensable condition or disability that resulted from combat wounds or service trauma?

Do you have a nursing degree?

Do you have a service-connected and compensable dental disability?

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

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 members of your family or household have any of the following conditions? (Check all that apply.)

Do you or any of your family or household members suffer from an injury or illness?

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

Do you own savings bonds?

Do you speak English fluently?

Do you travel for either of the following:

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

Does your condition prevent you from doing any of the following:

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

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

From what age have you or a member of your family or household had this disability, illness or injury?

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

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 as a result of 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 many are blind or disabled?

How many brothers and/or sisters live with you who are under age 18 or are students, ages 18 to 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 to 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:
Black Lung benefits
Bureau of Indian Affairs benefits
Insurance, annuity or Individual Retirement Account (IRA) payments
Pensions (including employer, union, Federal, state, local, or foreign government, military pensions or disability benefits)
Railroad Retirement Board benefits
Unemployment Compensation or Worker’s Compensation benefits
U.S. or foreign Social Security benefits (do not include Supplemental Security Income payments)
Veterans compensation or pension (including similar benefits from foreign countries)
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 level of health insurance coverage?

How would you characterize your income?

How would you describe your role as a parent or caregiver? (Check all that apply.)

If you are a veteran, did you serve on active duty in any of the following areas? (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? Example: 35

In which U.S. State do you live?

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

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 considered fatal or long-term (lasting 12 months or more)?

Is your spouse, or are your parents or children, currently receiving (or know that they might be eligible to receive) benefits from any of the following programs? (Check all that apply.)

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 that occurred outside of the United States?

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

Were you a prisoner of 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 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 housing/living situation prior to the disaster? (select all that apply)

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

What is the age of any children for whom you are responsible? (Check all that apply.)

What is the highest grade or level of education 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)? Example: 1345

What is your current employment status?

What is your current grade point average? Example: 3.54

What is your current military status?

What is your current spouse's date of birth? (Enter date in mm/dd/yyyy format.)

What is your date of birth? (Enter date in mm/dd/yyyy format.)

What is your gender?

What is your household's annual income before taxes? Example: 25000

What is your level of Servicemembers' Group Life Insurance (SGLI) coverage?

What is your race or ethnicity? (Check all that apply.)

What length of time, in years, did you or your family member serve in the military? Example: 12

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

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

What type of benefits are you looking for?

What was the date of your current marriage? (Enter date in mm/dd/yyyy format.)

What was the date of your parent's death? (Enter date in mm/dd/yyyy format.)

What was your child's date of death? (Enter date in mm/dd/yyyy format.)

When did you become disabled? (Enter date in mm/dd/yyyy format.)

Where do you live?

Which of the following (if any) describe your current and/or past professional experiences? (Check all that apply.)

Which of the following apply to your service in the railroad industry? (Check all that apply.)

Which of the following benefits do you receive, or do you believe you may be eligible to receive? (Check all that apply.)

Which of the following options 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 Benefits.gov 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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