DRAFT
OMB Control Number: 2900-0609
Estimated Burden: 20 Minutes
Expiration Date: XX/XX/20XX
Survey of Veteran Enrollees’ Health and Use of Health Care
(2025/26/27)
Welcome to the 2025/26/27 Survey of Veteran Enrollees’ Health and Use of Health Care. This annual VA survey asks how Veterans use VA health services and what types of services they do or do not use. Your participation is voluntary, although we hope you will help us as we plan for the needs of those enrolled in VA health care. Even if you are not a current user of VA Health Care, your answers to the survey questions are important. This survey takes about 20 minutes to complete.
If you require assistance from another person to complete this survey, it is all right to ask another person to fill the survey out on your behalf as long as they are able to answer questions about your health care, health benefits, and health status.
Questions or concerns? Call the Survey of Enrollees Information Line at (number to be determined upon contract award) or send and e-mail to (e-mail to be determined upon contract award). Center staff are available seven days a week from 9:00 am to 9:00 pm Eastern Time.
Note: If you are a Veteran in crisis or concerned about a Veteran in crisis, please contact the Veterans Crisis Line at 1-800-273-8255 and Press 1, or text 838255, or chat online at VeteransCrisisLine.net.
VA BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 2900-0609, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 20 minutes per respondent, per year, including the time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions to reduce the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-0609 in any correspondence. Do not send your completed survey to this email address.
PRIVACY NOTICE: VA has determined that this collection is not subject to the requirements of the Privacy Act of 1974, and the particular notice and other requirements of the Act do not apply. Specifically, VA will not collect information about individuals and will not use the name or any other personal identifier to routinely retrieve records from the information collected or trace information back to the respondent. The information collected will become part of the system of records identified as 97VA105, “Consolidated Data Information System-VA” as set forth in the Compilation of Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html. VA will use survey feedback to assess Veterans’ access to, and use of, health care services. The results of this survey will lead to improvements in the quality of health care delivery and the Veteran experience. Participation in this survey is voluntary, and your failure to respond will have no impact on any benefits to which you are entitled.
Health Care Use
The following questions ask about your overall use of health care, including prescription medication, whether at VA or through other health care providers. We are interested in your general use of health care, reasons for using or not using different health care providers available to you, and in gathering more precise estimates of your use of both VA care and care outside of the VA.
Questions in brown font only asked in even years
Questions in blue font only asked in odd years
1. Please indicate who is completing this survey.
I am the Veteran named in the invitation letter.
I am completing the survey on behalf of the Veteran named in the invitation letter.
2. Please select ALL the ways you plan to use VA health care in the future.
Select all that apply
As main source of health care.
For a Service-Connected disability or health condition, either mental or physical.
For care of a specific non-service-connected disability or health condition, either mental or physical.
For special medical devices such as hearing aids, prosthetics or orthotics.
For long term care services (e.g, senior care, assisted living centers)
For prescriptions.
As a “safety net” to use only if needed.
Some other way.
No plans to use VA for health care GO TO QUESTION 3
2a. Thinking about the options you selected in the question above, please select the option that best describes the PRIMARY way {you plan/<NAME> plans} to use VA health care in the future.
Select only one.
As main source of health care.
For a service-connected disability or health condition, either mental or physical.
For care of a specific non-service-connected disability or health condition
For special medical devices such as hearing aids, prosthetics or orthotics.
For long term care services (e.g, senior care, assisted living centers)
For prescriptions.
As a “safety net” to use only if needed.
Some other way (Please specify): _ .
3. From (insert quarter preceding survey), how many outpatient visits or trips did you make to a VA provider or to a provider who was paid for fully or partially by VA? Please include in-patient visits as well as telehealth or video care. Please do not count dental, mental health or substance abuse visits, or trips to a pharmacy.
Your best guess is fine. For none, enter 0.
I I__I Visits or trips
4. From (insert quarter preceding survey), how many outpatient visits or trips did you make to any Non-VA doctor’s office, hospital, or outpatient clinic that were NOT paid for by VA? Please include in-patient visits as well as telehealth or video care. Please do not count dental, mental health or substance abuse visits, or trips to the pharmacy. Your best guess is fine. For none, enter 0.
I I__I Visits or trips
5. How many different prescription medications did you use in the last 30 days? Include both VA and non-VA prescriptions. Your best guess is fine. For none, enter 0.
I I__I Prescriptions [0-50] [NUMERIC VALUES ONLY]
6. Of these prescription medications, how many did you obtain from VA? Your best guess is fine. For none, enter 0.
I I__I Prescriptions [0-50] [NUMERIC VALUES ONLY]
7. In (insert year), how many overnight hospital stays did you have that were at a VA facility or that were paid for fully or partially by VA? Please do not count domiciliary stays, residential rehabilitation care, or stays in a nursing home or community living center. Your best guess is fine. For none, enter 0.
I I__I__I Stays [0-366] [NUMERIC VALUES ONLY]
8. In (insert year), how many overnight hospital stays did you have that were NOT paid for by VA? Please do not count domiciliary stays, residential rehabilitation care, or stays in a nursing home or community living center. Your best guess is fine. For none, enter 0.
I I__I__I Stays [0-366] [NUMERIC VALUES ONLY]
9. Have you used ANY health care services not provided or not paid for by VA? Do not count dental, mental health, or substance abuse visits, or trips to a pharmacy.
Yes, for all or most of my health care needs
Yes, for some of my health care needs
No, for none of my health care needs GO TO QUESTION 11
No, I do not have any health care needs GO TO QUESTION 11
The following statements are possible reasons why you used health care services other than VA for some or all of your health care.
10. For each statement, please indicate if the statement is a “Major reason”, “Minor reason” or “Not a reason” that you use other health care services not provided or paid for by VA.
|
Major reason |
Minor reason |
Not a reason |
a. I have access to health care that is better quality than what VA provides. |
O |
O |
O |
b. I have a provider outside of VA that I prefer. |
O |
O |
O |
c. I have access to health care that is easier to get to than the VA. |
O |
O |
O |
d. I have a provider that offers appointments at more convenient times than you can get at VA. |
O |
O |
O |
e. I had prior experiences with VA care that I was dissatisfied with. |
O |
O |
O |
f. I am unsure what services I am eligible to receive from the VA |
O |
O |
O |
g. I had a condition requiring immediate attention and could not get an appointment at VA |
O |
O |
O |
h. There are medical services in the community that are not available to me at VA. |
O |
O |
O |
i. I do not feel welcomed at VA |
O |
O |
O |
j. I use non-VA providers for routine items such as flu shots, vaccines or blood pressure checks. |
O |
O |
O |
11. How important are each of the following factors to you when selecting a health care provider?
|
Not an important factor |
A slightly important factor |
A somewhat important factor |
A moderately important factor |
An extremely important factor |
a. Cost paid by you. |
O |
O |
O |
O |
O |
b. Easy parking |
O |
O |
O |
O |
O |
c. Availability of transportation |
O |
O |
O |
O |
O |
d. Travel time or distance |
O |
O |
O |
O |
O |
e. Hours of operation |
O |
O |
O |
O |
O |
f. Physical appearance of location |
O |
O |
O |
O |
O |
g. Professionalism of health care providers |
O |
O |
O |
O |
O |
h. Professionalism of office staff |
O |
O |
O |
O |
O |
i. Insurance coverage for the health services that you need. |
O |
O |
O |
O |
O |
j. Availability of specific medical services |
O |
O |
O |
O |
O |
k. Having a provider who shares the same cultural background with me (e.g., age, gender, race) |
O |
O |
O |
O |
O |
l. Having a provider with a military background |
O |
O |
O |
O |
O |
12. Do you currently use any of the following holistic approaches for your health care needs? (Please select the option that best describes your use and interest for each approach).
|
Yes, through a VA program or a program paid for by VA |
Yes, through a program NOT paid for by the VA |
Yes, through both VA programs and programs NOT paid for by VA |
No, I do/ not use this approach, but would be interested if available at the VA |
No, I am not interested in this approach |
No, I am unfamiliar with this approach. |
a. Acupuncture |
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b. Meditation |
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c. Guided Imagery |
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d. Massage therapy |
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e. Chiropractic |
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f. Biofeedback |
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g. Clinical hypnosis |
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Insurance/Health Benefits
Are you currently covered by any of the following types of health insurance or health coverage plans in addition to your VA health benefits?
13. Insurance through a current or former employer or union (yours or another family member)
Yes (If yes, complete 13a and 13b)
No
13a. What type of plan is this?
Health Maintenance Organization
Preferred Provider Organization
Catastrophic Only Health Plan
Other
13b. Does this other health plan include prescription drug coverage?
Yes
No
14. Insurance purchased directly from an insurance company (by you or another family member)
Yes (If yes, complete 14a and 14b)
No
14a. What type of plan is this?
Health Maintenance Organization
Preferred Provider Organization
Catastrophic Only Health Plan
Other
14b. Does this other health plan include prescription drug coverage?
Yes
No
15. Medicare, for people 65 and older, or people with certain disabilities
Yes (if Yes, complete 15a and 15b)
No
15a. Which type of Medicare Plan do you have?
Original Medicare (also known as Fee for Service)
Medicare Advantage also known as Part C)
I don’t know
15b. Are you enrolled in Medicare Part D, also known as Medicare Prescription Drug Plan?
Yes
No
16. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
Yes
No
17. TRICARE or other military health care
Yes
No
18. Indian Health Service
Yes
No
19. Any other type of health insurance or health coverage plan
Yes (If Yes, please specify _____________________)
No
Health and Well-Being
VA, along with other health care delivery systems, recognizes the importance of well-being in a person’s overall health status. Well-being includes physical health AND social, financial, mental, and spiritual health. The following questions seek to understand how you rate your well-being in these areas.
20. How would you rate your physical health as compared to other people your age?
Poor
Fair
Good
Very good
Excellent
21. How would you rate your mental health as compared to other people your age, including your mood and your ability to think?
Poor
Fair
Good
Very good
Excellent
22. How often do you get the social and emotional support you need?
Never
Rarely
Sometimes
Usually
Always
23. For these questions, please consider the most important things that you do, or wish to do, in your daily life. (This might include having a job, spending time with family and friends, participating in leisure-time activities, or managing your health or finances, for example.) If you are not sure which response to choose, please make your best guess.
Over the past three months, what percentage of the time have you been:
23 a. Fully satisfied with how these things are going?
None of the time |
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All of the time |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
23 b. Regularly involved in things that are important to you?
None of the time |
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All of the time |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
23 c. Functioning your best in the most important things you do?
None of the time |
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All of the time |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
Assistance Needs
The following questions ask about your ability to perform certain tasks common in daily life. They are designed to help VHA to better understand the ability of enrolled Veterans to live independently in their communities.
24. Because of a physical, mental, or emotional condition, do you have serious
difficulty concentrating, remembering, or making decisions?
Yes
No
25. Do you have serious difficulty walking or climbing stairs?
Yes
No
26. Do you have difficulty dressing or bathing?
Yes
No
27. Because of a physical, mental, or emotional condition, do you have difficulty
doing errands alone such as visiting a doctor’s office or shopping?
Yes
No
28. Are you currently receiving assistance from family, friends, neighbors, or others for daily activities such as dressing, bathing, household chores, preparing meals, or doing errands?
Yes, for all or most of daily activities
Yes, for some daily activities
No, I am not currently receiving assistance for any daily activities and believe I need assistance GO TO Question 31
Does not apply — currently I do not have any assistance needs GO TO Question 32
29. Using the scale below, please tell us your comfort level with completing medical forms, such as those requested at a doctor’s office, on your own?
Very Comfortable
Somewhat Comfortable
Comfortable
Somewhat Uncomfortable
Very Uncomfortable
30. VA is interested in knowing if your -main caregiver is receiving any VA or non-VA caregiver support services. As far as you know, does your main caregiver receive caregiver support services from any programs? Note: VA programs include the VA Caregiver Support Program’s Program of Comprehensive Assistance for Family Caregivers (PCAFC) and Program of General Caregiver Support Services (PGCSS).
Select only one.
Yes, my main caregiver is enrolled in PCAFC GO TO Question 32
Yes, my -main caregiver is enrolled in PGCSS GO TO Question 32
Yes, my -main caregiver is enrolled in a VA program, but I’m not sure which GO TO Question 321
Yes, my -main caregiver is enrolled in a program that is NOT sponsored by VA
Yes, my main caregiver is enrolled and receives support from both programs sponsored by VA and programs not sponsored by VA
No, my main caregiver does not receive support services from any program
I don’t know if my -main caregiver is receiving any support services
31. Are you AWARE of VA programs that may be available to support your main caregiver? These include the VA Caregiver Support Program’s Program of Comprehensive Assistance for Family Caregivers (PCAFC) and Program of General Caregiver Support Services (PGCSS).
Yes, my -main caregiver is aware of these programs
No, my main caregiver is not aware of these programs
I don’t know if my main caregiver is aware of these programs or not
Tobacco/E-Cig Use
VA has strived to provide assistance to those who wish to stop smoking and tobacco use. The next few questions ask about your cigarette smoking or other tobacco use and any attempts you may have made to quit.
32. Have you smoked at least 100 cigarettes in your entire life?
Yes
No GO TO Question 37
33. Do you now smoke cigarettes every day, some days, or not at all?
Every day
Some days
Not at all GO TO Question 36 (even years), 37 (odd years)
34. During the past 12 months, have you stopped smoking for more than one day because you were trying to quit smoking?
Yes
No GO TO Question 37
35. Did you use either non-nicotine prescription medications or nicotine replacement (NRT) therapy during your most recent quit attempt? Note: non-nicotine medications refer to bupropion (common brand names such as Zyban or Wellbutrin) or varenicline (common brand name Chantix). NRT refers to products such as nicotine patches or gum.
Yes
No
GO TO Question 37
36. How long has it been since you last smoked cigarettes regularly?
Within the past year (less than 1 year ago)
Within the past 5 years (1 year, but less than 5 years ago)
Within the past 10 years (5 years, but less than 10 years ago)
10 years or more
Never smoked regularly
37. Do you currently use chewing tobacco, snuff, or snus every day, some days, or
not at all?
Every day
Some days
Formerly used
Never used
38. Do you currently use e-cigarettes or other electronic vaping products (including electronic hookahs, vape pens, or e-cigars) every day, some days, or not at all?
Every day
Some days
Formerly used
Never used
Digital Access
Health care systems throughout the country are taking advantage of new technologies to provide easier access to health care. In addition, medical technology is always improving and increasingly allows for some conditions to be monitored or even diagnosed without having to travel to a traditional doctor’s office. The next few questions ask about your internet access whether through desktop and laptop computers, cell phones, tablets, or other mobile devices. They also ask about your interest in using these technologies for your own health care. This information will only be used to inform research.
39. Do you or any member of your household have access to the Internet using the following:
|
Yes |
No |
39a. Cellular data plan for a smartphone or mobile device? |
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39b. Broadband (high speed) internet service such as cable, fiber optic, or DSL service installed in your household |
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39c.Satellite Internet service installed in your household |
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39d. Dial-up Internet service installed in your household |
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39e. Some other service |
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40. If you do not use/have access to the Internet, what are the reasons?
Select all that apply.
My location is not served by an Internet service provider
I am not comfortable using computers
I am not comfortable using smart phones or tablets
I don’t want to pay for Internet service
I don’t want to pay for equipment needed to access the Internet (e.g., a computer or smart phone)
I am not interested in using the Internet
Other
NA/I have access to the Internet
41. Please indicate how WILLING you would be to do each of the following on a personal computer or mobile device?
|
Very willing |
Somewhat willing |
Not willing |
I already do this |
This activity does not apply to me |
41 a. Complete an online health assessment |
O |
O |
O |
O |
O |
41 b. Access my health record |
O |
O |
O |
O |
O |
41 c. Access laboratory or X-ray test results |
O |
O |
O |
O |
O |
41 d. Use an “app” to track health such as blood pressure or weight. |
O |
O |
O |
O |
O |
41 e. Get health related text messages on my mobile device, such as appointment reminders |
O |
O |
O |
O |
O |
41 f. Communicate with my health care providers using secure digital technology |
O |
O |
O |
O |
O |
42. Are you interested, at least occasionally, in meeting with a Mental Health provider remotely, using the Internet, for appointments?
I already do this and it is my preference
I already do this, but I prefer in-person visits/appointments
I am interested in this but have not yet because I lack adequate Internet access
I am interested in this but I need assistance to use a computer or mobile device
I am interested in this but have not yet for another reason
I am NOT interested in this
I do not have a need for mental health care
43. Are you interested, at least occasionally, in meeting with your NON-Mental Health provider (e.g. primary care, dermatologist, cardiologist) remotely, using the Internet, for appointments?
I already do this and it is my preference
I already do this, but I prefer in-person visits/appointments
I am interested in this but have not yet because I lack adequate Internet access
I am interested in this but I need assistance to use a computer or mobile device
I am interested in this but have not yet for another reason
I am NOT interested in this
44. How willing are you to use the Internet to do the following as part of a remote consultation/appointment?
|
Very willing |
Somewhat willing |
Not willing |
I already do this |
This activity does not apply to me |
44 a. Use the Internet to share my health information (e.g. symptoms, photos) with a VA health care provider who uses that information to make decisions about my health care |
O |
O |
O |
O |
O |
44 b. Use the Internet to receive a medical opinion and directions from a VA health care provider who evaluated my health information |
O |
O |
O |
O |
O |
44 c. Use the Internet to share my health information (e.g. symptoms, photos) with a computer that evaluates my health information to make decisions about my health care without any interaction from a health care provider |
O |
O |
O |
O |
O |
44 d. Use the Internet to receive a medical opinion and directions from a computer that evaluated my health information without any interaction from a health care provider |
O |
O |
O |
O |
O |
Demographics
In this section, we would like to obtain information on your active-duty military history as well as general demographic information about you. This information will only be used to understand health care needs and expectations of people with similar backgrounds such as military experience, marital status, employment, gender, race or ethnicity and income. None of the information provided in this survey will be linked to your personal information.
45. Did you serve on active duty in the U.S. Armed Forces during the following time frames?
Select all that apply.
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46. Did {you/<NAME>} ever serve in a combat or war zone?
Yes
No
47. How would you best characterize your employment status?
Select only one.
Employed full-or part time (includes self-employment)
Unemployed, looking for work, or laid off GO TO Question XX
Retired] GO TO Question XX
Not currently looking for employment (for example, a student or on disability) GO TO Question XX
47a. Are you self-employed?
Yes
No
47b. How many jobs do you work?
Select only one.
One
Two
Three or more [3]
47c. On average, how many hours per week do you work?
Select only one.
Less than 20 hours
20-34 hours
35-59 hours
60 or more hours
48. Which of the following best describes your current marital status?
Currently married
Widowed
Divorced
Separated
Never married
Living with a partner, unmarried
49. Not including yourself, how many dependents do you currently have? A “Dependent” is anyone who relies on you for at least half of their financial support and can be a child, elderly parent, or other family member. For none, enter 0.
I I__I Dependents [0-97] [NUMERIC VALUES ONLY]
49 a. How many of these Dependents are under the age of 18 (0 to 17 years of age)? For none, enter 0.
I I__I Dependents [0-97] [NUMERIC VALUES ONLY]
50. What is your race and/or ethnicity? Select all that apply. Note, you may report more than one group.
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino(a)
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White
51. What is the highest degree or level of school you have completed?
Some high school, no diploma
High school diploma (including GED)
Some college credit, no degree
Associate’s degree (AA/AS)
Bachelor’s degree (BA/BS)
Technical School or Trade School
Graduate degree (MA/MS, PhD, Post Doc, MD, JD)
Prefer not to answer
52. Please indicate the range that best describes your 20XX total annual HOUSEHOLD income.
Less than $10,000
$10,000 – $14,999
$15,000 – $19,999
$20,000 – $24,999
$25,000 – $34,999
$35,000 – $49,999
$50,000 – $74,999
$75,000 - $ 99, 999
$100,000 or over
Prefer not to answer
VA Form 10-0400
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Bowman, Laura |
| File Modified | 0000-00-00 |
| File Created | 2024-12-21 |