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pdfP2P Provider
V1 DRAFT
11/21/2022
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 988 (Press 1), or 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:3 minutes
Help us serve you better
We want to hear about your experience. Let us know how VA
collaboration with national and local community partners influenced your
ability to connect with Peer-to-Peer participants. Your answers to these
questions directly help us improve our services.
Your responses are confidential.
This survey should take you approximately 3 minute to complete.
Please indicate your relationship with the participant.
Existing Relationship
New Relationship
Are you assisting a participant with enrollment to VA Healthcare services?
Yes
No
VA provided me with the resources (e.g., platform to connect, marketing, networking) I
needed to be successful in assisting participants.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Collaborating with VA was easy.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
VA support allowed me to effectively connect participants with Peer-to-Peer services.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I felt respected and valued working with VetXL and VEAC.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Required
I trust VA’s collaboration with community partners.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I would recommend VA’s collaboration with community partners to other Peer-to-Peer
providers.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
Would you like to provide additional feedback with a concern, compliment, or
recommendation about your experience(s) with VA’s collaboration with national and
local community partners? Please select from one of the following options.
Select your response
Compliment
Concern
Recommendation
Will not provide additional feedback
Use the text box below to enter details of the additional feedback (optional). Please do not
include any personally identifiable information, Social Security Number, Veteran ID, or
medical information, but do provide details about your experience.
0/400
Logic: This appears if “Compliment”, “Concern”, or “Recommendation” is selected to the previous question
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 3 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.
Privacy Policy
P2P Provider
V1 DRAFT
11/21/2022
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 988 (Press 1), or 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:3 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 3 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.
Privacy Policy
P2P Participant
V1 DRAFT
11/21/2022
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 988 (Press 1), or 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:3 minutes
Help us serve you better
We want to hear about your experience. Let us know about the impact of
your connection with a Peer-to-Peer provider. Your answers to these
questions directly help us improve our services.
Your responses are confidential.
This survey should take you approximately 3 minute to complete.
Do you currently receive VA health care services or VA benefits, such as compensation,
pension, education, home loan, or pre-burial benefits?
Yes
No
Unsure
What information and/or services did you receive from your participation with the Peerto-Peer provider? Select all that apply.
Information about the Peer-to-Peer organization
Services in the community (e.g., counseling, healthcare, financial, transportation, etc.)
Information about VA Healthcare and Benefits
Connecting with a Peer-to-Peer provider was easy. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I was able to get my information and/or service support needs met during my Peer-toRequired
Peer connection.
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I felt respected and valued during my participation in this Peer-to-Peer connection. Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I trust the Peer-to-Peer provider I connected with.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
I would recommend this Peer-to-Peer provider to others.
Required
Strongly
Disagree
Disagree
Neither Agree
nor Disagree
Agree
Strongly
Agree
1
2
3
4
5
What best describes you as you’re participating in this Peer-to-Peer connection?
Veteran
Active Military/National Guard/Reserve
Family Member
Caregiver
Survivor
Please indicate when you served in the military. Select all that apply.
Logic: This appears if “Veteran” or “Active Military/National Guard/Reserve” is selected to the previous question
World War II: 12/7/1941 – 12/31/1946
Korea Conflict: 06/27/1950 – 01/31/1955
Vietnam Era: 02/28/1961 – 05/07/1975
Cold War/Peacetime Era: 1975 – 1991
Gulf War 1 Era: 08/02/1990 – 10/06/2001
Post 9/11 Era: 10/07/2001 – Present
Other
What is your gender?
Female
Male
Transgender Female
Transgender Male
Non-Binary/Third Gender
Choose Not to Respond
[Logic: when Choose Not to Respond is selected, no other option can be selected in the question]
Other
What race/ethnicity do you identify with? Please select all that apply.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
What is your age group?
<30
30-39
40-49
50-59
60-69
>=70
What ZIP code do you consider your primary residence? (Enter ‘00000’ if using an APO/FPO)
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 3 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.
Privacy Policy
P2P Participant
V1 DRAFT
11/21/2022
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 988 (Press 1), or 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:3 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 3 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.
Privacy Policy
| File Type | application/pdf |
| File Modified | 2022-12-15 |
| File Created | 2022-12-15 |