Veterans Transportation Service Data Collection

OMB No. 2900-XXXX
Estimated Burden: 5 mins
OMB EXP Date: XX/XX/XXXX

Veterans Transportation Service Data
Collection Telephonic Script
THE PAPERWORK REDUCTION ACT OF 1995: This information is collected in accordance with section
3507 of the Paperwork Reduction Act of 1995. Accordingly, 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 complete this survey will average 5 minutes. This includes the time
it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer
satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and
desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery
by helping to achieve transportation services. Participation is voluntary and failure to respond will have no
impact on benefits to which you may be entitled.

PRIVACY ACT INFORMATION: The authority for collection of the requested information on this form is 38
U.S.C. 501 and 111A. The purpose of collecting this information is to assist VA in providing transportation
services to eligible persons. You do not have to provide the requested information but if any or all of the
requested information is not provided, it may delay or result in denial of your request for transportation
services. Failure to furnish the requested information will have no adverse impact on any other VA benefit to
which you may be entitled. The responses you submit are considered confidential and may be disclosed
outside VA only if the disclosure is authorized under the Privacy Act, including the routine uses identified in
the VA system of records 54VA16, titled "Health Administration Center Civilian Health and Medical Program
Records -VA", as set forth in the Compilation of Privacy Act Issuances via online GPO access at
http://www.gpoaccess/privacyact/index.html. For example, information on this form may be disclosed to
contractors, trading partners, health care providers and other suppliers of health care services to determine
your eligibility for medical benefits and payment for services. Disclosure of Social Security number(s) of
those for whom benefits are claimed is requested under the authority of Title 38, U.S.C., and is voluntary.
Social Security numbers will be used in the administration of veterans benefits, in the identification of
veterans or persons claiming or receiving VA benefits and their records and may be used for other purposes
where authorized by Title 38, U.S.C., and the Privacy Act of 1974 (5 U.S.C. 552a) or where required by
other statute.

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OMB No. 2900-XXXX
Estimated Burden: 5 mins
OMB EXP Date: XX/XX/XXXX
Upon answering the phone the following information is to be collected:

1.

What is your full name (First, M.I., Last)?

2.

What is your address?

3.

What is your Primary Phone number?

4.

What is your Secondary Phone number?

5.

What is your Official Phone number?

6.

What is your Gender?

7.

What is your Mobility Type?

8.

How many Attendant(s), if any, will be joining you?

9.

What is the Mobility of any Attendants joining you?

10.

Who is your Emergency Contact(s)?

11.

Do you have any assistance needs?

12.

Do you have any Travel Restrictions?

13.

Are you eligible for Beneficiary Travel?

14.

Are you Homeless?

15.

Are you a Veteran of OEF/OIF/OND?

16.
If we will be picking you up or dropping you off at a location other than your address, where
will that be?
17.

What time is your appointment?

18.

Will a guest be accompanying you?

19.

If you are a guest, what is the name of the person you are accompanying?

20.
What category best describes your status in the context of your travel? Enrolled Veteran;
Non-Enrolled Veteran; Servicemember; Family Caregiver; Person Receiving Counseling, Training, or
Mental Health Services; Attendant; CHAMPVA beneficiary; Guest
21.

Is the appointment recurring and if so is it daily, weekly, monthly?

22.
Is there anything else we need to know to assist with your transportation? (NOTE: Additional
clarifying questions may be needed to prepare travel arrangements, such as descriptions of the area if
address numbers are not viewable from the street.)

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