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pdfCOVID-19 Vaccine Trial - EMD_1
V5 DRAFT
10/29/20
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: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 1 minute
Help us serve you better.
We want to hear about your recent experience with the VA COVID-19
Research website. By indicating how much you agree or disagree with
the statements below, you directly help us improve VA services.
This survey should take approximately 1 Minute to complete.
Please select the reason(s) you did not participate in a clinical trial after being contacted
by the VA study team. (Select all that apply) Required
I felt there were too many visits required
I felt it was too inconvenient (for example, needed travel, work conflict, or
other reasons)
I felt there was too much work (for example, daily logs)
I was concerned about the product being tested
I was not compensated
Other
Do you think having a research website for other types of research studies, other than
COVID-19, would be helpful? Required
Yes
No
Please select additional VA research topics you would be interested in learning about.
(Select all that apply) Required
Cancer
Diabetes
Infectious diseases
Heart diseases
HIV/AIDS
Aging
Post-Traumatic Stress Disorder (PTSD)
Traumatic Brain Injury (TBI)
Gulf war
Burn pits
Agent Orange
Suicide prevention
Other Mental health
Other
[Sub question is only presented if user selects yes for prior queston]
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA.1 VA may
utilize individual Veteran survey data from this survey or other sources to ensure the final scores truly and accurately
represent the experiences of Veterans.2 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 1 minute 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 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 https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private to the extent provided
by law.
[Logic: 1). Required if Service Recovery. 2). Required unless exception.]
Privacy Policy
COVID-19 Vaccine Trial
V5 DRAFT
10/29/20
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: 2900-0876
Expiration: 03/31/2023
Estimated Burden: 1 minute
Thank you for choosing VA.
The U.S. Department of Veterans Affairs uses these surveys to collect
your feedback in order to continuously to improve your experience with
VA services.
Please visit VA.gov to explore benefits, resources, and information
at VA.
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA.1 VA may
utilize individual Veteran survey data from this survey or other sources to ensure the final scores truly and accurately
represent the experiences of Veterans.2 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 1 minute 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 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 https://www.reginfo.gov/public/do/PRAMain. Information gathered will be kept private to the extent provided
by law.
[Logic: 1). Required if Service Recovery. 2). Required unless exception.]
Privacy Policy
| File Type | application/pdf |
| File Modified | 2020-11-03 |
| File Created | 2020-11-03 |