Vre_2020

Public reporting for this collection of information is estimated to average 20 minutes per response, OMB Number: 2900-0786

including the time for reviewing the instructions, searching for existing data sources, gathering Expiration Date: XX/XX/20XX

and maintaining the data needed, and completing and reviewing the collection of information. An

agency may not conduct or sponsor and a person is required to respond to a collection of information

unless it displays a currently valid OMB control number.

PIN: WVMILABC

1. Are you currently participating in the VR&E program?

MARK ONLY ONE.

3. During the past 12 months, did you receive any of the following benefits from Social Security?

Yes No

_ SKIP TO ITEM 3

MARK ALL THAT APPLY.

Supplemental Security Income (SSI) Social Security Disability Insurance

1a. If you answered No to Question #1, why are you no longer participating in the program?

MARK ONLY ONE.

Successfully completed the program _ SKIP TO ITEM 3 Requested to have my case closed

VR&E requested to have my case closed _ SKIP TO ITEM 3

(SSDI)

Medicare Retirement

Survivors or Dependent Benefits Other (specify):

Did not receive Social Security benefits

2. If you withdrew from the program, what was your reason?

MARK ALL THAT APPLY.

Medical problems Financial problems Family responsibilities

Found a job prior to program completion Transportation difficulties

Program did not meet my needs Program requirements were too difficult Lost interest

To pursue another education benefit (Ch33, State Voc Rehab, etc.)

Other (specify):

PLEASE CONTINUE ON NEXT PAGE

4. Are you currently working at a job or business?

MARK ONLY ONE.

6. During the past 12 months, how much did you earn from all jobs or businesses before taxes and other deductions?

Yes No

_ SKIP TO ITEM 5

Yearly salary:

$ _.

4a. What is the main reason you are not currently working?

Hourly rate: ^{$ .}

MARK ONLY ONE.

Ill,

Ill, ^{or disabled and unable to work} Retired

Taking care of home or family Going to school

Could not find work Doing something else Other:

5. During the past 12 months, how many months were you employed?

MARK ONE AND FILL-IN # OF MONTHS.

Months employed:

Was not employed at any time during the past 12 months

5a. During the past 12 months, how many hours per week did you usually work at your main job?

MARK ONE AND FILL-IN # OF HOURS.

Hours per week:

Was not employed at any time during the past 12 months

Was not employed at any time during

the past 12 months

7. If you were employed during the past 12 months, how much did counseling, training, job search assistance, or other VR&E assistance contribute to your success?

A lot Some A little None

Was not employed at any time during the past 12 months

7. What was your gross income during the past 12 months? (Your gross income includes income you received from all sources, before taxes, including earnings from a job, benefits received from government programs, and any retirement, pension, investing, or savings income that you receive regular payments from.)

$ _.

7. During the past 12 months, did you receive unemployment compensation?

Yes

^No _ SKIP TO ITEM 11

PLEASE CONTINUE ON NEXT PAGE

7. If you answered Yes to Question #9, how many weeks of unemployment did you receive?

Number of weeks:

14.

How many academic credit hours did you complete during the past 12 months?

1 to 10

11 to 20

21 to 30

31 to 40

41 or more

Credits were not recorded

Did not complete any credits this year

7. During the past 12 months, have you been enrolled in an Institution of Higher Learning (IHL)? (An Institution of Higher Learning is defined as a college, university, or similar institution, including a technical or business school, offering postsecondary level academic instruction that leads to an associate or higher degree if the school is empowered by the appropriate State education authority under State law to grant an associate or higher degree.)

Yes

15. How did you pay for this training? MARK ALL THAT APPLY.

VR&E Program (Chapter 31)

GI Bill (Chapter 30 or Chapter 33) Financial Aid/Pell Grant

Personal loan Personal funds Family support Other (specify):

^No _ SKIP TO ITEM 16

12. Were you in school part-time, full-time, or both?

Part-time Full-time

16. Did you receive any professional or trade certificates or licenses during the past 12 months?

Yes

Both part-time and full-time

13. Did you receive any of the following degree levels during the past 12 months?

MARK ALL THAT APPLY.

High school diploma or GED certificate Associates

Bachelors Masters Ph.D.

Other Professional Degree (e.g., M.D., J.D., Pharm.D.)

Did not complete a degree this year

^No _ SKIP TO ITEM 18

17. How many certificates or licenses did you receive, and what type were they? (e.g., CDL license, HVAC Certification, etc.)

Number of Certificate(s) or License(s):

Type of Certificate(s) or License(s):

PLEASE CONTINUE ON NEXT PAGE

17. Were you enrolled in any other education or training programs during the past 12 months?

MARK ALL THAT APPLY.

Non-College degree program (NCD) On-the-job training (OJT)

Volunteer

Non-paid work experience (NPWE) Apprenticeship

Special Employer Incentive (SEI) Compensated Work Therapy (CWT) Other (specify):

20. During the past 12 months, how many visits have you made to a Non-VA Medical facility?

PLEASE FILL-IN EACH ONE WITH A NUMBER. PUT ZERO IF YOU DID NOT MAKE A VISIT.

Enter the number of times you made...

1. Emergency visits:

2. 

   
   

   Routine and scheduled visits (checkups, screenings, etc.):

3. 

   
   

   Treatment visits (PT, OT, Psychology, etc.):

Was not enrolled in any other education or training programs during the past 12 months

19. During the past 12 months, how many visits have you made to a VA Medical facility?

PLEASE FILL-IN EACH ONE WITH A NUMBER. PUT ZERO IF YOU DID NOT MAKE A VISIT.

Enter the number of times you made...

21. During the past 12 months, what was your gross household income? (Your household income is the combined before-tax income of people who share their income and live in the same home. Typically, this would be you and your spouse.)

$ _.

21. Do you own your principal residence? (Your principal residence is the home where you live for at least half of the year.)

Yes No

1. Emergency visits:

2. 

   
   

   Routine and scheduled visits (checkups, screenings, etc.):

3. 

   
   

   Treatment visits (PT, OT, Psychology, etc.):

PLEASE CONTINUE ON NEXT PAGE

21. How many dependents do you currently have? (Dependents include spouses, children under 18, children between ages 18 and 23 who are attending school, children who are permanently incapable of self-support because of disabilities arising before age 18, and dependent parents.)

Number of Dependents:

Please specify what kind of dependents you have (spouse, child under 18, etc.).

Type of Dependent	Yes Or No
a. Spouse:	Yes No

Type of Dependent	Number (Write in a number.)
b. Children:
c. Other:

21. Thinking about ALL aspects of your experience with the VR&E program, please rate it overall, using a 1 to 9 scale where 1 is Unacceptable, 5 is Average, and 9 is Outstanding.

MARK ONLY ONE.

(Unacceptable)				(Average)				(Outstanding)
1	2	3	4	5	6	7	8	9

PLEASE CONTINUE ON NEXT PAGE

21. What is the primary reason you applied for the VR&E program? MARK ONLY ONE.

Get any job Get a better job

Further my education so I could become employed or qualify for a higher paying job Get a job that accommodated my disability

Start my own business

Get help to keep my current job

Improve my job-seeking skills so I could become employed

Career Counseling so I could best use my benefits to enter the right career Independent Living Services

Other (specify):

21. If you are working, does your current job generally match the training you received while you participated in the VR&E program?

Yes No

Somewhat

Not currently working

21. Thinking about your experience with the VR&E program, please rate the following statement, using a 1 to 9 scale where 1 is Strongly Disagree, 5 is Neither Disagree nor Agree, and 9 is Strongly Agree.

MARK ONLY ONE.

The VR&E program assisted in my ability to become employable.

(Strongly Disagree)

(Neither Disagree nor Agree)

(Strongly Agree)

1 2 3 4 5 6 7 8 9

PLEASE CONTINUE ON NEXT PAGE

21. Thinking about your experience with the VR&E program, please rate the following statement, using a 1 to 9 scale where 1 is Strongly Disagree, 5 is Neither Disagree nor Agree, and 9 is Strongly Agree.

MARK ONLY ONE.

The VR&E program assisted in my ability to live more independently.

(Strongly Disagree)

(Neither Disagree nor Agree)

(Strongly Agree)

1 2 3 4 5 6 7 8 9

Thank you for completing this year's survey.

PRIVACY ACT INFORMATION: The responses you submit are considered confidential (38 U.S.C. 5701). VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your response is voluntary.

RESPONDENT BURDEN: This form is used to assess and continually improve services. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 20 minutes to review the instructions, find the information, and complete this form. 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. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.