Web Survey: VA For National Veterans Creative Arts Festival (NVCAF)

OMB 2900-XXXX
Estimated Burden: 2.25 minutes
Expiration Date: XX-XX-XXXX

National Veterans
Creative Arts Festival

OMB 2900-XXXX

This information is collected in accordance with section 3507 of the Paperwork Reduction Act of
1995. Accordingly, VA 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 complete this survey will average 2.25 minutes. This includes the time it will take to read
instructions, gather the necessary facts and fill out the form. The results of this questionnaire will lead to
improvement in the quality of service delivery by helping to shape the direction and focus of specific
programs and services. Submission of this form is voluntary and failure to respond will have no impact
on benefits to which you may be entitled.
Privacy Act. Assurances of privacy are contained in 38 U.S.C. 5701 and 7332. The information
collected will become part of the Consolidated Health Record that complies with the Privacy Act of 1974.
These forms are part of the system of records identified as 121VA19 “National Patient Database – VA”
and 57VA135 “Voluntary Service Records – VA” as set forth in the Compilation of Privacy Act Issuances
via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.

VA Form 10108
DEC 2013

OMB 2900-XXXX
Estimated Burden: 2.25 minutes
Expiration Date: XX-XX-XXXX

National Veterans Creative Arts Festival
Thank you for agreeing to take this survey. Your responses will be kept in confidence
and will only be reported in aggregate. Your participation will provide us with important
information that will be used to better serve our Veterans.
1. What is your age?
17-25
26-35
36-45
46-55
56-64
65-74
75+
2. Are you…?
Male
Female
3. In which era did you serve? Please select all that apply.
OEF/OIF
Desert Storm
Korea
Vietnam
World War II
Other
4. Do you have a VA-rated Service Connected Disability?
Yes
No
5. Nature of illness/injury (choose PRIMARY one):
Traumatic Brain Injury (TBI)
Post-Traumatic Stress Disorder (PTSD)
Spinal Cord Injury (SCI)
Quadriplegic SCI Paraplegic SCI
Multiple Sclerosis
Amputation
Visual Impairment
Stroke
Other
VA Form 10108
DEC 2013

OMB 2900-XXXX
Estimated Burden: 2.25 minutes
Expiration Date: XX-XX-XXXX

6. How many years have you ad this illness/injury?
< 1 year
1-2 years
6-15 years
16-25 years

3-5 years
25+ years

7. Do you use a wheelchair or prosthetic limb on a daily basis?
Wheelchair
Prosthetic limb
Neither
8. Which of the following VA National Veterans Sports Programs & Special Events
have you participated in, if any? Please check all that apply.
National Veterans Creative Art Festival
National Disabled Veterans Winter Sports Clinic
National Veterans Golden Age Games
National Veterans TEE Tournament
National Veterans Wheelchair Games
National Veterans Summer Sports Clinic
9. For how many years have you participated in any VA National Veterans Sports
Programs & Special Events?
This is my first event
2-5
6-10
11+
10. How many years have you participated in the Creative Arts Festival?
This is my first year
2-5
6-10
11+
11. How often do you participate in therapeutic arts?
Daily
Seasonally
Weekly
Not at all
Monthly
12. How do you engage in therapeutic arts? Please check that apply.
VA programs
Veteran Service Organization therapeutic art programs
VA Form 10108
DEC 2013

OMB 2900-XXXX
Estimated Burden: 2.25 minutes
Expiration Date: XX-XX-XXXX

Community based creative arts & recreation programs
Individually / on my own
I don’t regularly engage in creative arts / recreation
Other
13. Which of the following, if any, does your VA therapist do to support your
participation in therapeutic art programs at home? (Check ALL that apply)?
Provide resources for community organizations
General orientation
Organized practices
Skills instruction
Equipment
None of the above
Other
14. For how many months, if any, did you train in preparation for this event?
11+ months prior to event
8-10 months prior to event
4-7 months prior to event
1-3 months prior to event
I did not train for the event
15. How likely are you to continue involvement in one or more of these sports when
you return home.
I definitely will not
I possibly will
I probably will
I definitely will
16. Please indicate the extent to which you agree or disagree with the following
statement: “Preparation and participation in the National Disabled Veterans Winter
Sports Clinic has taught me ways to be active in recreation in my home
community.”
Strongly disagree
Somewhat disagree
Neither agree nor disagree
Somewhat agree
Strongly agree

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Estimated Burden: 2.25 minutes
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17. To what extent would each of the following help you to be more involved in sports
on a regular basis? Please use the following rating scale.
a. Would not help
b. Some help
c. A fair amount of help
d. A lot of help
e. A tremendous amount of help
____ Education of community programs available in my area
____ Adaptive sports clinics to develop skills
____ VA staff support to introduce me to a local program for the first time
____ Adaptive equipment
18. Thinking specifically about this event, what is the SINGLE most important reason
you participated in this event?
Improve or maintain health.
Help other Veterans – peer mentor, advocate for new injuries and help with
adjustment.
Enhance / develop a social network.
Learn new adaptive sports & recreation activities.
Continue my rehabilitation.
Other (please specify)
19. When you participate in leisure activities, do you usually do this alone or with
others?
(Choose ONE answer)
Mostly alone
Mostly with friends
Mostly with family members
With a combination of family and friends
I do not participate in leisure activities, such as movies, sports, restaurants, etc.
20. To what extent did each of the following influence your decision to participate in
this event? Please use the following rating scale.
1. No impact
2. Slight impact
3. Moderate impact
4. Major impact
____ My doctor or therapist recommended it

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____ I enjoy sports
____ I am an active person
____ I am concerned about staying healthy
____ I like to compete in sports events with other Veterans
____ I like the interaction with other Veterans
____ I want to gain experience with different sports
____ My friend or family member encouraged me to participate
____ Other
21. Check all that apply:
First time entering the National Veterans Creative Arts Competition
First time participant at the National Veterans Creative Arts Festival
Visual Artist
Performer
22. What creative arts events have you participated in over the past year?
Check all that apply:
VA Craft Clinic
VA Writing Clinic
Art Instructor
VA Music Therapy
VA Choir
Community Theater
Clinic
VA Band
Independent Writing
VA Art Therapy
VA Guitar
Church Choir
Clinic
Workshop
VA Drama Clinic
VA Creative Arts
Competition
Other (please describe):
22. Performers only:
In preparing for the National Veterans Creative Arts Festival, (Check all that apply.)
I have read the Festival Participant Responsibilities and am prepared to engage
in rehearsals, the stage show performance, creative arts workshops and other
events described.
I have rehearsed the production music and am ready for rehearsals at the
Festival.
I have not been able to rehearsal because
Other
23. Artists only:
In preparing for the National Veterans Creative Arts Festival, (Check all that apply.)

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I have read the Festival Participant Responsibilities and am prepared to engage
in art workshops, interaction sessions, art exhibit display and other events
described.
I do not feel I am prepared because
Other
24. Is there any other feedback you’d like to provide:
[free text entry]