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pdfCommunity Pulse Check
V1.0
06/17/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0770
Expiration: 09/30/2020
Estimated Burden: 5 minutes
Help us serve you better
We want to hear about your perception of the VA’s engagement in your
local community. By answering the following questions, you directly help
us improve VA services.
This survey should take you approximately 5 minutes to complete.
Which of these terms best represents you? Required
Select your response
Please select a State or Territory to narrow down the list of possible VA Medical Centers and
VA Community-Based Outpatient Clienics. The following questions are required.
Which State or Territory is your Healthcare Facility in?
Select your response
Which City is your Healthcare Facility in?
Select your response
Which is your nearest VA Healthcare Facility?
Select your response
Which ZIP code do you live in? (Enter ‘00000’ if using an APO/FPO.) Required
Do you currently receive VA healthcare services? Required
Yes
No
Do you currently receive VA benefits? Required
Yes
No
Are you a member of a CVEB (Community Veteran Engagement Board)? Required
Yes
No
Next
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will have
no impact on VA benefits or services to which you may currently be receiving. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/
public/do/PRAMain.
Privacy Policy
Community Pulse Check
V1.0
06/17/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0770
Expiration: 09/30/2020
Estimated Burden: 5 minutes
We want to hear about your perception of the VA’s engagement in your
local community. By indicating how much you agree or disagree with
the statements below, you directly help us improve VA services.
My local community provides supportive resources for Veterans, families, caregivers,
and survivors. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
VA and community partners are coordinating support to help Veterans, families,
caregivers, and survivors access and receive services in my local community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Local VA and local community groups are working in partnership to address gaps in
services. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
VA transition support services help transitioning service members, families, caregivers,
and survivorsto integrate into their community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Access to VA services and benefits is improving for Veterans, families, caregivers, and
survivors in my local community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Veterans, families, caregivers, and survivors are able to navigate non-medical VA
benefits in my local community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Veterans, families, caregivers, and survivors are able to navigate VA healthcare services
in my local community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Community-based resources are healthcare, benefits, and services not provided by VA.
Access to community-based resources is improving for Veterans, families, caregivers,
and survivors in my community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
The Community Care program (formerly the CHOICE program) is helping to meet the
healthcare needs of Veterans, families, caregivers, and survivors in my community.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Suicide prevention resources are available and accessible in my community. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
Not
Applicable
1
2
3
4
5
N/A
Which of the following VA suicide prevention services in your community are you
familiar with? (Select all that apply).
▢
▢
▢
▢
▢
▢
▢
Veterans Crisis Line (VCL)
Vet Center
Community Based Outpatient Clinic (CBOC)
Suicide Prevention Coordinators at local VA
Medication Disposal Program at local VA
VHA Mental Health Services
Save Trainings Online
▢
▢
▢
▢
▢
▢
▢
Veterans Benefits Administration (VBA)
Mobile Vet Center
MISSION ACT
VA Telehealth
Gun Lock Distribution
VA Emergency Departments
VA Chaplaincy
Finish
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will have
no impact on VA benefits or services to which you may currently be receiving. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/
public/do/PRAMain.
Privacy Policy
Community Pulse Check
V1.0
06/17/19
Working Draft, Pre-Decisional, Deliberative Document - Internal VA Use Only
The VA provides free, confidential support 24/7 for Veterans and their family and friends.
If you are in crisis, contact the Veterans Crisis Line by dialing 1 (800) 273-8255 (Press
1), or texting 838255, or visiting https://www.veteranscrisisline.net. If you are homeless
or at risk of homelessness, contact the National Call Center for Homeless Veterans
(NCCHV) by dialing 1 (877) 424-3838 or visiting https://www.va.gov/HOMELESS/.
OMB Number: 2900-0770
Expiration: 09/30/2020
Estimated Burden: 5 minutes
Thank you for choosing VA
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously improve your experience with VA
services.
Please visit VA.gov to explore benefits, resources, and information
at VA.
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Title 38, United
States Code, allows us to ask for this information. We estimate that you will need an average of 5 minutes to review the
instructions and complete this survey. The results of this survey will be used to inform opportunities for program
improvement in the quality of VA services. Participation in this survey is voluntary, and your decision not to respond will have
no impact on VA benefits or services to which you may currently be receiving. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if
this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/
public/do/PRAMain.
Privacy Policy
| File Type | application/pdf |
| File Modified | 2019-06-24 |
| File Created | 2019-06-18 |