Tracked Changes Enrollment Survey - SAH

Voice of the Veteran Servicing Satisfaction 06/27/12

Specially Adapted Housing

Sample population definition: Individuals who are eligible for an SAH grant, and in the past 12 months have including (1) received an approval on their grant and are currently somewhere in post-approval, (2 have had all their funds dispersed and final accounting is not yet complete, and (3) have had all of their funds dispersed and final accounting is complete [DO NOT INCLUDE]

[DO NOT DISPLAY/IDENTIFY SECTION HEADERS. DISPLAY SINGLE QUESTION PER PAGE.]

Benefit Eligibility and Assessment

1. Before we begin, please indicate your relation to the Veteran eligible for or in receipt of the Specially Adapted Housing grant:(Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

   1. I am the Veteran [1]

   2. I am the spouse [2]

   3. I am a family member or friend [3]

   4. I am the caretaker [4]

   5. Other (specify)[97] _________

   6. Prefer not to answer [98]

(If you have submitted an application for Specially Adapted Housing Benefits, please continue, otherwise skip to Q63)

2. At the beginning of the grant application process, how much did you understand the Specially Adapted Housing grant program? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Completely

2. Mostly

3. Somewhat

4. Only a little

5. Not at all

3. Was this your first time submitting an application for your Specially Adapted Housing benefit? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

   1. Yes

   2. No

   3. Don’t know or not sure

(Ask Q4 if Q3 is no, all others, go to Q5)

4. How many times have you used your SAH grant? [DROP DOWN LIST. SINGLE RESPONSE]

   1. 1

   2. 2

   3. 3

   4. Don’t know or not sure

5. Thinking about your most recent Specially Adapted Housing benefit application, what method did you use to apply for your benefit? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

   1. Veterans Online Application

   2. Mail

   3. In person at a Regional Office

   4. In person at a Veterans Service Organization, e.g., Disabled American Veterans, Veterans of Foreign Wars, Paralyzed Veterans of America, etc.

   5. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

   6. Don’t know or not sure

6. For this most recent application, did you fill out the application form yourself? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

   1. Yes

   2. No, I had assistance

   3. Don’t know or not sure

(Ask Q7 if Q6 is yes, otherwise go to Q8)

7. If you were updated on the status of your SAH application, how were you updated on the status of your Specially Adapted Housing application? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

   1. I was not contacted

   2. Mail

   3. E-mail

   4. Phone

   5. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

   6. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

8. After you submitted your most recent SAH application, did a SAH agent contact you within 30 days? [RADIO BUTTONS. SINGLE RESPONSE]

   1. Yes

   2. No

   3. Don’t know or not sure

(If Yes to Q8, answer Q9-10, all others go to Q11)

9. How soon after you were contacted did you meet with a Specially Adapted Housing representative from VA in person for your initial appointment? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

   1. Less than 30 days

   2. More than 30 days

   3. Don’t know or not sure

10. When you met with the Specially Adapted Housing representative in person, which of the following did they discuss, if any: (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Freedom of choice

    2. Temporary Residence Adaptation grant option

    3. The grant program and benefits

    4. Veteran’s responsibility

    5. Design and construction/remodeling considerations

    6. Personal finances

    7. Escrow and release of funds

    8. Your desired modifications

    9. Requirements for modifications

    10. Limits of the grant amount

    11. Your individual concerns

    12. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    13. None of the above [MUTUALLY EXCLUSIVE RESPONSE]

    14. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

11. If your SAH grant was ever delayed, why was there a delay? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Incomplete information

    2. Missing information

    3. Awaiting rating decision from C&P to determine eligibility

    4. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    5. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

12. From the time you submitted your SAH application, how long did it take to receive your approval notification? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Less than 30 days

    2. More than 30 days

    3. Don’t know or not sure

The following question asks you to rate various aspects of your experience with Specially Adapted Housing, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. [SHOW ON SAME PAGE AS THE QUESTION THAT FOLLOWS]

13. Please rate your experience with the SAH grant application process on the following items: [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND ATTRIBUTES/RESPONSES IN ROWS (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, ALTERNATE SHADES IN ROWS. SINGLE RESPONSE PER ROW. RANDOMIZE ALL ATTRIBUTES EXCEPT THE LAST ONE.]

    1. Ease of completing the application [ALLOW N/A RESPONSE]

    2. Timeliness of initial eligibility notification [ALLOW N/A RESPONSE]

    3. Flexibility of application methods [ALLOW N/A RESPONSE]

    4. Overall rating of application process

Grant Process

Grant Planning

(If you have received approval notification on your grant application, whether or not your grant has been disbursed, please answer Q14-27, all others go to Q28)

14. Which adaptive items did you/do you intend to use your SAH grant for? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Ramps (exterior or interior)

    2. Grab bars

    3. Wider door opening

    4. Wider hallways

    5. Accessible bathroom(s)/shower(s)

    6. Accessible kitchen

    7. Accessible bedroom(s)

    8. Elevators, ramps, or entrances on ground floor

    9. Level thresholds

    10. Lighting

    11. Garage/carport construction or modification

    12. Construction of emergency entrances/exits

    13. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    14. Don't know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

15. If authorized, did the SAH agent talk to your family and/or friends about your health care or adaptive item(s)? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

    4. Interview with SAH agent not yet conducted

16. Did the SAH agent talk to you and/or your family and friends about the Temporary Residence Adaptation (TRA) grant? [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

    4. Interview with SAH agent not yet conducted

17. Did you request a list of contractors from VA? [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

(If you have completed the planning for your modifications or adaptations, please answer Q18-Q39, all others go to Q40)

18. How many bids did you receive for your desired modifications/adaptations or new home construction? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Number of bids (0-99)__________________ [NUMERIC TEXT BOX. ACCEPTABLE RANGE 0-99.]

    2. Have not yet begun bid process [CHECK BOX MUTUALLY EXCLUSIVE RESPONSE]

    3. Don't know or not sure [CHECK BOX MUTUALLY EXCLUSIVE RESPONSE]

19. If any, which desired adaptive items were not covered as a result of an insufficient grant amount? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Ramps (exterior or interior)

    2. Grab bars

    3. Wider door opening

    4. Wider hallways

    5. Accessible bathroom(s)/shower(s)

    6. Accessible kitchen

    7. Accessible bedroom(s)

    8. Elevators, ramps, or entrances on ground floor

    9. Level thresholds

    10. Lighting

    11. Garage/carport construction or modification

    12. Construction of emergency entrances/exits

    13. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    14. All desired adaptive items were covered [MUTUALLY EXCLUSIVE RESPONSE]

20. During the grant process, did you have to submit any required documentation (e.g., building plans or financial statements) more than once? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

(Ask Q21-22 if Q20 is Yes, all others go to Q23)

21. How many times did you have to submit required documentation? (Open Capture)

    1. Number of times (0-99)_____________ [NUMERIC TEXT BOX; ACCEPT 0-99]

    2. Don’t know or not sure [CHECK BOX. MULTIPLE RESPONSE.]

22. Why did you have to resubmit required documentation? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Incomplete documentation

    2. Missing documentation

    3. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    4. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

23. Did the SAH agent talk to your contractor about the planned modifications? [RADIO BUTTONS. SINGLE RESPONSE]

1. Yes

2. No

3. Don’t know or not sure

Home Modification/Construction Process

(Answer Q24-Q38 if you have completed the modification process, whether or not your grant funds have been disbursed, all others skip to Q39)

24. How long did it take for your new specially adapted house to be built or existing home to be modified? Please consider only the timeframe it took from the beginning of construction till the construction was complete. (Open Capture)

    1. Months (0-99 months) _____________ [NUMERIC TEXT BOX; ACCEPT 0-99]

    2. Modifications still in process [CHECK BOX; MUTUALLY EXCLUSIVE]

    3. Don’t know or not sure [CHECK BOX; MUTUALLY EXCLUSIVE]

    4. Not applicable [CHECK BOX; MUTUALLY EXCLUSIVE]

25. Was the work on your or your family members’ home completed as planned? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

    4. Not applicable

26. Was the work completed on time? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

27. Please rate your experience with the contractor on the following items, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND ATTRIBUTES/RESPONSES IN ROWS (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, ALTERNATE SHADES IN ROWS. SINGLE RESPONSE PER ROW. RANDOMIZE ALL ATTRIBUTES EXCEPT THE LAST ONE.]

    1. Courtesy of the contractor [ALLOW N/A RESPONSE]

    2. Knowledge of the contractor [ALLOW N/A RESPONSE]

    3. Timeliness of the modification/construction process [ALLOW N/A RESPONSE]

    4. Overall rating of contractor

Completion of the Grant Process

28. How long has your current SAH application been pending? [RADIO BUTTONS. SINGLE RESPONSE]

1. < 30 days

2. 1-12 Months

3. >1 year

4. Don’t know or not sure

29. What is the reason your grant application is pending? [CHECK BOXES. MULTIPLE RESPONSE]

    1. Need to submit required documentation

    2. Waiting for confirmation from VA

    3. Waiting on medical rating from compensation services

    4. Other

    5. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

30. Was your SAH agent the same person throughout the entire process (i.e., initial interview, planning, and processing of grant)? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

(Ask Q31 if Q30 is No, all others go to Q32)

31. Did the change in SAH agents create a problem for you? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

32. Did your SAH agent involve you in decisions about the planned adaptations? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don't know or not sure

33. How many appointments did you have with your SAH Agent before your grant process was complete? (Mark only one)

1. Number of appointments (0-99)____________ [NUMERIC TEXT BOX. ACCEPTABLE RANGE 0-99]

2. Don’t know or not sure [CHECK BOX. MUTUALLY EXCLUSIVE RESPONSE]

34. Using the same scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average, please rate your experience with your Specially Adapted Housing agent(s) during the SAH grant application process on the following items: [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND ATTRIBUTES/RESPONSES IN ROWS (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, ALTERNATE SHADES IN ROWS. SINGLE RESPONSE PER ROW. RANDOMIZE ALL ATTRIBUTES EXCEPT THE LAST ONE.]

1. Promptness of scheduling appointments or returning calls [ALLOW N/A RESPONSE]

2. Courtesy of the agent

3. Knowledge of the agent

4. Agent’s concern for your needs

5. Timeliness of completing your adaptation plan

6. Overall SAH agent experience

35. Were your Specially Adapted Housing grant funds available for initial disbursement: (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Early

2. On time

3. Late

4. Don’t know or not sure

36. Was your Specially Adapted Housing grant the amount you expected? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Yes

2. No

3. Don’t know or not sure

37. Based on your grant coverage, were you able to obtain all modifications/adaptations that you needed? [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

38. If you were not able to use the SAH grant program, what would be your most likely housing situation? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Living in assisted living facility

2. Living in the same house or apartment without adaptations

3. Living with a family member or a friend

4. Other

5. Don't know or not sure

The following question asks you to rate various aspects of your experience with Specially Adapted Housing benefits, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. [SHOW ON SAME PAGE AS THE QUESTION THAT FOLLOWS]

39. Please rate your Specially Adapted Housing grant on the following items: [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND ATTRIBUTES/RESPONSES IN ROWS (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, ALTERNATE SHADES IN ROWS. SINGLE RESPONSE PER ROW. RANDOMIZE ALL ATTRIBUTES EXCEPT THE LAST ONE.]

1. Amount of grant coverage [ALLOW N/A RESPONSE]

2. Usefulness of benefit or services [ALLOW N/A RESPONSE]

3. Timeliness of receiving benefit payment or services [ALLOW N/A RESPONSE]

4. Overall rating of benefit payment

40. How much do you currently understand the Specially Adaptive Housing grant program? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Completely

2. Mostly

3. Somewhat

4. Only a little

5. Not at all

Benefit Information

(If you have not yet submitted an application for SAH benefits, answer Q41, all others go to Q42)

41. Prior to receiving this survey, were you aware of the Specially Adapted Housing (SAH) and Temporary Residence Adaptation (TRA) grant program? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

(Ask Q42-46 If submitted an application or aware of the Specially Adapted Housing grant program, all others skip to Q47)

42. How did you FIRST learn about the Specially Adapted Housing benefit? (Mark only one) If you are unsure, please indicate the first way you remember learning about the Specially Adapted Housing benefit [RADIO BUTTONS. SINGLE RESPONSE]

    1. VA website

    2. VetSuccess.gov

    3. eBenefits.va.gov

    4. Mail (from VA)

    5. VA phone number (800-827-1000)

    6. Transition Assistance Program/Disabled Transition Assistance Program briefings

    7. Veterans Service Organizations, e.g., Disabled American Veterans, Veterans of Foreign Wars, Paralyzed Veterans of America, etc. (Specify) ___________________[TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    8. VA medical center

    9. VA Vet center

    10. In person at a Regional Office

    11. Social media websites (e.g., Facebook, Twitter, etc.)

    12. Visit from a VA employee

    13. Other Veterans

    14. Internet (excluding VA and social media sites)

    15. Friends or family

    16. Information came with notification/ratings letter

    17. Other publications (e.g., Army Times, local newspaper, etc.)

    18. Other (Specify) ___________________[TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    19. Don’t know or not sure

43. What method(s) do you MOST FREQUENTLY use to obtain general information about VA’s Specially Adapted Housing benefits or services? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Phone

    2. Mail

    3. E-mail

    4. In person at a Regional Office

    5. Veterans Service Organizations, e.g., Disabled American Veterans, Veterans of Foreign Wars, Paralyzed Veterans of America, etc. (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    6. Disabled Veterans’ Outreach Program

    7. VA website

    8. VetSuccess.gov

    9. eBenefits.va.gov

    10. Social media websites (e.g., Facebook, Twitter, etc.)

    11. Other websites (excluding VA or social media sites)

    12. VA medical center

    13. VA Vet center

    14. Friends or family

    15. Other publications (e.g., Army Times, local newspaper, etc.)

    16. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    17. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

    18. None of the above [MUTUALLY EXCLUSIVE RESPONSE]

44. How frequently would you like to receive communications (e.g., e-mails, letters, newsletters, etc.) from VA about Specially Adapted Housing benefits or services? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Weekly

    2. Monthly

    3. Quarterly (every 3 months)

    4. Semi-annually (twice per year)

    5. Annually (once per year)

    6. Never

    7. Don’t know or not sure

45. How would you like to receive information from VA about Specially Adapted Housing benefits or services? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Phone

    2. Mail

    3. E-mail

    4. VA website

    5. Social media websites (e.g., Facebook, Twitter, etc.)

    6. In person at a Regional Office

    7. Veterans Service Organizations, e.g., Disabled American Veterans, Veterans of Foreign Wars, Paralyzed Veterans of America, etc. (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    8. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    9. Don’t know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

The following question asks you to rate various aspects of your experience with Specially Adapted Housing benefits, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. [SHOW ON SAME PAGE AS THE QUESTION THAT FOLLOWS]

46. Please rate your experience in obtaining information about your Specially Adapted Housing grant on the following items: [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND ATTRIBUTES/RESPONSES IN ROWS (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, ALTERNATE SHADES IN ROWS. SINGLE RESPONSE PER ROW. RANDOMIZE ALL ATTRIBUTES EXCEPT THE LAST ONE.]

    1. Ease of accessing information [ALLOW N/A RESPONSE]

    2. Availability of information [ALLOW N/A RESPONSE]

    3. Clarity of information [ALLOW N/A RESPONSE]

    4. Frequency of information provided by VA [ALLOW N/A RESPONSE]

    5. Usefulness of information [ALLOW N/A RESPONSE]

    6. Overall rating of information

Contact with VA

47. Did you contact anyone from VA about your Specially Adapted Housing benefit (excluding contact related to an initial appointment with an SAH agent)? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

(Ask Q48-Q54 if Q47 is yes, all others skip to Q55)

48. How many times did you have contact with VA regarding your Specially Adapted Housing benefit? (Open Capture)

    1. Number of contacts (0-99)__________ [NUMERIC TEXT BOX. ACCEPTABLE RANGE 0-99.]

    2. Don’t know or not sure [CHECK BOX. MUTUALLY EXCLUSIVE RESPONSE.]

49. Which of the following best describes the reason for your most recent contact? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Resolve a problem

    2. Ask a question

    3. Request a change to your records/provide information

50. Can you briefly describe the nature of your most recent contact? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Report the death of an individual who received VA benefits

    2. Submit a new grant application

    3. Appeal a decision on a grant application

    4. Question or problem about status of grant application

    5. Question or problem with the application

    6. Question about inconsistent information received from different VA or SAH agents

    7. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

51. Thinking about your most recent contact, how did you contact VA? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. VA toll-free phone number

2. VA Regional office phone number

3. VA Main office phone number

4. Fax

5. Website

6. E-mail

7. Mail

8. In person

52. Was your most recent issue resolved? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Yes

2. No

(Ask Q53 if Q52 is No, otherwise go to Q54)

53. Why wasn’t your most recent issue resolved? [CHECK BOXES. MULTIPLE RESPONSE]

    1. Did not receive all of the information required

    2. Received incorrect information

    3. Was referred to the incorrect office/person

    4. Waiting for follow-up from VA

    5. Other (Specify) ____________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    6. Don't know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

54. Thinking of your most recent contact with the VA, how would you rate your overall customer service experience with the VA or VA representatives using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND SINGLE ROW (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, SINGLE RESPONSE PER ROW.]

Overall Experience with Benefit

55. What was/is the total cost of your current modification/adaptation project? (Open Capture)

    1. Approximate cost (0-999,999)__________________ [NUMERIC TEXT BOX; ACCEPT [0-999,999)]

    2. Don’t know or not sure [CHECK BOX; MUTUALLY EXCLUSIVE]

56. Thinking about ALL aspects of your experience with Specially Adapted Housing benefits (e.g., grant application process, grant planning process, home modification/construction process, completion of the grant process, obtaining information about your grant, contacting VA), please rate VA overall, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. (Mark only one) [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND SINGLE ROW (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, SINGLE RESPONSE PER ROW.]

(If you have completed the entire grant process and all of your funds have been disbursed, please answer Q57, all others go to Q58)

57. Do your housing adaptations help you live more independently? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

Overall Experience with VA

58. Taking into consideration all of the non-medical benefits (e.g., education, compensation, pension, home loan guaranty, vocational rehabilitation and employment, insurance, etc.) you have applied for or currently receive, please rate your experience with VA overall, using a scale of 1 to 10 where 1 is Unacceptable, 10 is Outstanding, and 5 is Average. (Mark only one) [SHOW RESPONSES IN GRID WITH 10-POINT SCALE IN COLUMNS AND SINGLE ROW (SEE JDPA CONVENTIONS DOCUMENT PG. 1 FOR SPECIFIC DETAILS OF LAYOUT). EVENLY SPACED RADIO BUTTONS/COLUMNS, SINGLE RESPONSE PER ROW.]

59. Based on your experiences with VA, how likely are you to recommend to other Veterans VA benefits or services? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Definitely will not

    2. Probably will not

    3. Probably will

    4. Definitely will

60. How likely are you to inform other Veterans about your experience with VA benefits or services? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Definitely will not

    2. Probably will not

    3. Probably will

    4. Definitely will

61. How much do you agree with the following statement: "Receiving a Specially Adapted Housing Grant makes me feel that the Nation recognizes my service to our country." (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

1. Strongly disagree

2. Somewhat disagree

3. Neither agree nor disagree

4. Somewhat agree

5. Strongly agree

62. Now think about your experiences with all the services provided by the Department of Veterans Affairs (which include healthcare, benefits programs, or memorial services). Please tell us how you feel about the following statements. (Mark only one per statement)

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I got the service I needed
It was easy to get the service I needed
I felt like a valued customer
I trust VA to fulfill our country’s commitment to veterans

Reasons for Not Using the SAH Grant

(If you applied and have not used or you have not yet applied for your SAH grant, please answer Q62-65, all others skip to Q66)

(If you have applied and not yet used your SAH grant funds, answer Q62, otherwise skip to Q63)

63. If you have applied and not yet used your SAH grant funds, do you intend to use them in the future? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. Don’t know or not sure

(If you have not yet applied for your SAH grant, please answer Q63, all others skip to Q64)

64. If you have not yet applied for the SAH grant program, what is the major reason you have not submitted an application? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Unsure how to apply

    2. Difficulty completing application forms

    3. Application forms asked for information VA already should have

    4. Current home meets my needs

    5. Do not want to use the grant

    6. Plan on using the grant in the future

    7. Application/grant process was too time consuming

    8. Application/grant process was too complex

    9. Grant amount was not large enough to meet my needs

    10. Elected to use alternate source of funding

    11. Not applicable

65. What is the major reason preventing you from using the grant? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Application was denied

    2. Plan on using the grant in the future

    3. No longer need the grant

    4. Did not have enough help from VA in completing application

    5. Application/grant process was too complex

    6. Grant amount was not large enough to meet my needs

    7. Elected to use alternate source of funding

    8. Waiting for response from VA

    9. Unable to find a contractor willing to complete the required adaptations for the grant amount

    10. Not applicable

66. Please select which of the following, if any, would influence your decision about how or when to use your SAH grant funds. (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Ability to use grant on multiple occasions

    2. Ability to use grant funds while still on active duty

    3. Ability to adapt a family member's home

    4. None of the above [MUTUALLY EXCLUSIVE RESPONSE]

About You

67. Which adaptive items do you feel are necessary for living independently? (Mark all that apply) [CHECK BOXES. MULTIPLE RESPONSE]

    1. Ramps (exterior or interior)

    2. Grab bars

    3. Wider door opening

    4. Wider hallways

    5. Accessible bathroom(s)/shower(s)

    6. Accessible kitchen

    7. Accessible bedroom(s)

    8. Elevators, ramps, or entrances on ground floor

    9. Level thresholds

    10. Lighting

    11. Garage/carport construction or modification

    12. Construction of emergency entrances/exits

    13. Other (Specify) ___________________ [TEXT BOX, FORCE TEXT IF RESPONSE IS SELECTED, 50 CHARACTER MAX.]

    14. Don't know or not sure [MUTUALLY EXCLUSIVE RESPONSE]

68. Do you have any other comments or concerns about your experience? (Open Capture) [OPEN-END. TEXT BOX. 1000 CHARACTER MAX.]

____________________________________________________

As a reminder, your responses will be kept completely confidential and your email address will not be sent to VA with any responses on this survey.

69. Would you like to provide an e-mail address so VA can contact you with general information about VA benefits and services? (Mark only one) [RADIO BUTTONS. SINGLE RESPONSE]

    1. Yes

    2. No

    3. I do not have an e-mail address

    4. Prefer not to answer

(Ask Q69 if Yes in Q68)

70. Please enter your preferred e-mail address where you would like to be contacted: (Open Capture)

    1. E-mail: [OPEN CAPTURE. 100 CHARACTER MAX.]

JDPA: V9

OMB Control Number: 2900-0782 27