2900-0876-AA2-3 COVID-19 Vaccine Trial Study Team

COVID-19 Vaccine Trial - Study Team
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.
On a scale 1-5 was it helpful to get a vetted list?
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

How was your experience using the User interface? (Scale 1-5)
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

How responsive was our team when and if you needed help? (Scale 1-5)
Strongly
Disagree

Disagree

Neither Agree
nor Disagree

Agree

Strongly
Agree

1

2

3

4

5

How could we make your experience better?

0/400

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