Download:
pdf |
pdfLong COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: Long COVID Experience Survey (5 minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your opinion matters.
Dear ,
The Department of Veterans Affairs (VA) would like to hear
about your experience with Long Covid. Completion of the
survey is voluntary, and the results will assist us to
continue to innovate and support others like yourself.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. 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 5 minutes 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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: We still want to hear about your experience with Long COVID (5
minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your feedback is important to us.
Dear ,
We care about your experience. Please
take this 5 minute survey to let us know about your
experience with Long Covid.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. 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 5 minutes 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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 minutes
Help us serve you better
We are concerned about Veterans who may be impacted by ongoing
COVID symptoms. We are asking you and other Veterans like you to
take this very short survey so that we may provide the kind of care
needed for all. Please help us in this very important effort!
This survey should take you approximately 5 minute to complete.
1. Have you ever been tested for COVID?
Yes, I used a self-test/mail-in test
Yes, I used a community/public health clinic or non-VA health practice
No, I’ve never been tested
Logic: When selected skip to question 3
2. Have you ever tested positive for COVID?
Yes
No
Other
3. Have you ever suspected you had COVID?
Yes
No Logic: When selected END SURVEY
Other
4. Have you been hospitalized due to COVID?
No
Yes, in the VA system
Yes, outside the VA system
5. What was your general health before you had (or suspected you had) COVID?
Poor
Fair
Good
Very Good
Excellent
1
2
3
4
5
6. What COVID symptoms (ongoing, new, or worsening) are you struggling with the most in
your daily life? (select all that apply)
Logic: If answer with A AND B, C, D, or E, please indicate Error for inconsistent answer
None Logic: When selected skip to question 16
Fatigue
Brain Fog (Lack of focus or mental clarity)
Shortness of breath
Coughing
Other symptoms
7. How much has COVID created new health problems or worsened pre-existing
conditions, compared to before you got COVID?
Completely
Greatly
Moderately
Slightly
Not At All
1
2
3
4
5
8. Do you have someone (a paid or unpaid caregiver) who helps you with daily activities
because of ongoing, new, or worsening COVID symptoms?
No
Yes, but they are not enrolled in the VA Caregiver Support Program
Yes, and they are enrolled in the VA Caregiver Support Program
Other
9. How much do COVID symptoms (ongoing, new, or worsening) still impact your
activities of daily living (e.g., bathing, toileting, dressing, mobility)?
Completely
Greatly
Moderately
Slightly
Not At All
1
2
3
4
5
10. In what ways have COVID symptoms (ongoing, new, or worsening) specifically
impacted your employment? (select all that apply)
Logic – if answer with A AND C, D, or E please indicate error for inconsistent answer
I am retired
No impact on my employment
It has hurt my ability to find job
My job performance has suffered
It’s caused me to miss work
11. Where have you received medical care for your COVID needs?
Haven’t received medical care for COVID
Logic: When selected skip to question 14
Within the VA system
Outside the VA system Logic: When selected skip to question 14
Both within and outside the VA system
12. Which of the following VA providers have you seen specifically for your COVID symptoms
(ongoing, new, or worsening)? If you haven’t seen one of these, please leave question blank.
(select all that apply)
Primary Care Provider
Neurologist (brain)
Cardiologist (heart)
Physical therapist (movement)
Pulmonologist (lungs)
13. All my VA healthcare providers seem informed and up-to-date about all of my
ongoing COVID care.
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
2
3
4
5
1
Not Applicable
(N/A)
14. Would you like VA to help you manage or continue managing your COVID symptoms
(ongoing, new, or worsening)?
No
Yes
I’m not sure
15. When you consider your options for your care, please rank your preference with 1
being most preferred. Click on the down arrow beside each option
Video telehealth visit
Phone visit
In-person visit
No preference
16. Which of the following types of support do you need to help you manage your
COVID symptoms (ongoing, new, or worsening)? (select all that apply)
Logic – if answer with A AND B, C, or D, please indicate Error for inconsistent answer
None at this time
Medical care (e.g., access to specialists, treatments, procedures, mental health counseling, etc.)
Support (e.g., medical equipment, caregivers support, spiritual support, COVID information, etc.)
Other
Required
17. I trust VA to provide healthcare for ongoing COVID needs.
Strongly Disagree
Disagree
Neither
Agree
Strongly
Agree
1
2
3
4
5
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 5 minutes 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
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 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 5 minutes 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
Long COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: Long COVID Experience Survey (5 minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your opinion matters.
Dear ,
The Department of Veterans Affairs (VA) would like to hear
about your experience with Long Covid. Completion of the
survey is voluntary, and the results will assist us to
continue to innovate and support others like yourself.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. We are asking for this information so that you can
provide compliments, recommendations, or concerns to VA. By filling out this survey, you are
authorizing VA database access to retrieve Veteran contact information to follow up with you
accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you
have shared regarding your experience with VA. Your contact information and response may be
referred to the Veterans Crisis Line if an automated review indicates your response may be
concerning. The Veterans Crisis Line may contact you for follow up as a result of that referral. 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. This information is collected in
accordance with section 3507 of the Paperwork Reduction Act of 1995. 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 5 minutes
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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: We still want to hear about your experience with Long COVID (5
minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your feedback is important to us.
Dear ,
We care about your experience. Please
take this 5 minute survey to let us know about your
experience with Long Covid.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. We are asking for this information so that you can
provide compliments, recommendations, or concerns to VA. By filling out this survey, you are
authorizing VA database access to retrieve Veteran contact information to follow up with you
accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you
have shared regarding your experience with VA. Your contact information and response may be
referred to the Veterans Crisis Line if an automated review indicates your response may be
concerning. The Veterans Crisis Line may contact you for follow up as a result of that referral. 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. This information is collected in
accordance with section 3507 of the Paperwork Reduction Act of 1995. 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 5 minutes
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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 minutes
Help us serve you better
Our records indicate that at some point you were diagnosed with COVID.
We are asking you and other Veterans like you to take this very short
survey so that we may provide the kind of care needed for all. Please
help us in this very important effort!
This survey should take you approximately 5 minute to complete.
1. My health has recovered completely from COVID.
Strongly Disagree
Disagree
Neither
Agree
Strongly
Agree
1
2
3
4
5
2. Where have you received medical care for your ongoing COVID needs?
Haven’t received medical care for ongoing COVID
Within the VA system
Outside the VA system
Both within and outside the VA system
3. How much do COVID symptoms (ongoing, new, or worsening) still impact your
activities of daily living (e.g., bathing, toileting, dressing, mobility)?
Completely
Greatly
Moderately
Slightly
Not At All
1
2
3
4
5
4. What COVID symptoms (ongoing, new, or worsening) are you struggling with the most in
your daily life? (select all that apply)
Logic: If answer with A AND B, C, D, or E, please indicate Error for inconsistent answer
None Logic: When selected skip to question 16
Fatigue
Brain Fog (Lack of focus or mental clarity)
Shortness of breath
Coughing
Other symptoms
5. Do you have someone (a paid or unpaid caregiver) who helps you with daily activities
because of ongoing, new, or worsening COVID symptoms?
No
Yes, but they are not enrolled in the VA Caregiver Support Program
Yes, and they are enrolled in the VA Caregiver Support Program
Other
6. In what ways have COVID symptoms (ongoing, new, or worsening) specifically
impacted your employment? (select all that apply)
Logic – if answer with A AND C, D, or E please indicate error for inconsistent answer.
I am retired
No impact on my employment
It has hurt my ability to find job
My job performance has suffered
It’s caused me to miss work
7. Which of the following types of support do you need to manage your COVID
symptoms (ongoing, new, or worsening)? (select all that apply)
Logic – if answer with A AND B, C, or D, please indicate Error for inconsistent answer
None at this time
Medical care (e.g., access to specialists, treatments, procedures, mental health counseling, etc.)
Support (e.g., medical equipment, caregivers support, spiritual support, COVID information, etc.)
Other
8. Which of the following equipment would help you with your COVID symptoms
(ongoing, new, or worsening)? (select all that apply)
Logic – if answer A AND B, C, or D please indicate error for inconsistent answer
Don’t need this kind of equipment
Portable oxygen units
Mobility assistance (e.g., walker, cane, wheelchair, shower chair, bedside commode)
Other
9. When you consider your options for your care, please rank your preference with 1
being most preferred. Click on the down arrow beside each option
Video telehealth visit
Phone visit
In-person visit
No preference
10. All my VA healthcare providers seem informed and up-to-date about all of my
ongoing COVID care.
Strongly
Disagree
1
Disagree
Neither
Agree
Strongly
Agree
2
3
4
5
Not Applicable
(N/A)
11. Overall, I am satisfied with the in-person COVID follow-up care I receive(d) from VA.
Have not had
in-person
Strongly
Strongly
Neither
Disagree
Agree
follow-up from
Disagree
Agree
VA
1
2
3
4
5
12. Overall, I am satisfied with the telehealth (video and telephone) COVID follow-up
care I receive(d) from VA.
Have not had
telehealth
Strongly
Strongly
Neither
Disagree
Agree
follow-up from
Disagree
Agree
VA
1
2
3
4
5
13. Overall, I am satisfied with my ongoing COVID care.
Strongly
Disagree
1
Disagree
Neither
Agree
Strongly
Agree
2
3
4
5
Not getting
follow-up care
14. I trust VA to provide healthcare for ongoing COVID needs. Required
Strongly Disagree
Disagree
Neither
Agree
Strongly
Agree
1
2
3
4
5
15. Please provide us with any additional comments regarding your VA care for your ongoing
COVID symptoms or needs. 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
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. Your contact information and response may be referred to the Veterans Crisis Line if an automated
review indicates your response may be concerning. The Veterans Crisis Line may contact you for follow up as a result of
that referral. 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. This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. 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
5 minutes 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
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 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.
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. Your contact information and response may be referred to the Veterans Crisis Line if an automated
review indicates your response may be concerning. The Veterans Crisis Line may contact you for follow up as a result of
that referral. 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. This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. 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
5 minutes 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
Long COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: Long COVID Experience Survey (5 minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your opinion matters.
Dear ,
The Department of Veterans Affairs (VA) would like to hear
about your experience with Long Covid. Completion of the
survey is voluntary, and the results will assist us to
continue to innovate and support others like yourself.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. We are asking for this information so that you can
provide compliments, recommendations, or concerns to VA. By filling out this survey, you are
authorizing VA database access to retrieve Veteran contact information to follow up with you
accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you
have shared regarding your experience with VA. Your contact information and response may be
referred to the Veterans Crisis Line if an automated review indicates your response may be
concerning. The Veterans Crisis Line may contact you for follow up as a result of that referral. 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. This information is collected in
accordance with section 3507 of the Paperwork Reduction Act of 1995. 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 5 minutes
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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
Working Draft, Pre-Decisional, Deliberative document – Internal VA Use Only
EMAIL SUBJECT LINE: We still want to hear about your experience with Long COVID (5
minutes)
EMAIL PREHEADER: Tell us about your experience with Long COVID.
OMB Number: 2900-0876
Expiration: 02/28/2026
Estimated Burden: 5 minutes
Your feedback is important to us.
Dear ,
We care about your experience. Please
take this 5 minute survey to let us know about your
experience with Long Covid.
Take Our Survey
Thank you,
Veterans Experience Office
Department of Veterans Affairs
Whether you’re just getting out of the service or you’ve been a civilian for years, the VA Welcome Kit
can help guide you to the benefits and services you’ve earned.
The Veterans Crisis Line provides free, confidential support for Veterans and their families and
friends in crisis. Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), or text 838255 to receive
confidential support 24/7 (System of Records Notice VA158VA10NC5). Visit https://
www.veteranscrisisline.net for more information.
Additionally, the National Call Center for Homeless Veterans (NCCHV) provides free, confidential
support for Veterans and their family members and friends who are homeless or at risk of
homelessness. Veterans can either call or chat online with the National Call Center for Homeless
Veterans where trained counselors are ready to talk confidentially 24 hours a day, 7 days a week.
Dial 1 (877) 424-3838 or visit https://www.va.gov/HOMELESS/ to receive confidential support.
Please do not reply to this email - it is unmonitored.
If you wish to share your feedback, please do so by .
You received this email because you provided your email address to VA. If you would like to opt out
from receiving future surveys, please click below.
Unsubscribe from this VA Survey | Privacy Policy
By filling out this survey, you are authorizing VA database access to retrieve Veteran contact
information to follow up with you accordingly for purposes of service recovery, potential crisis, or to
learn more about feedback you have shared regarding your experience with VA. 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. We are asking for this information so that you can
provide compliments, recommendations, or concerns to VA. By filling out this survey, you are
authorizing VA database access to retrieve Veteran contact information to follow up with you
accordingly for purposes of service recovery, potential crisis, or to learn more about feedback you
have shared regarding your experience with VA. Your contact information and response may be
referred to the Veterans Crisis Line if an automated review indicates your response may be
concerning. The Veterans Crisis Line may contact you for follow up as a result of that referral. 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. This information is collected in
accordance with section 3507 of the Paperwork Reduction Act of 1995. 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 5 minutes
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 [logic: Hyperlink: https://www.va.gov/privacy-policy/]
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 minutes
Help us serve you better
Our records indicate that at some point you were diagnosed with long
COVID. We are asking you and other Veterans like you to take this very
short survey so that we may provide the kind of care needed for all.
Please help us in this very important effort!
This survey should take you approximately 5 minute to complete.
1. Where have you received medical care for your Long COVID needs?
Haven’t received medical care for long COVID Logic: When selected skip to question 3
Within the VA system
Outside the VA system Logic: When selected skip to question 3
Both within and outside the VA system
2. If you are receiving Long COVID care from VA, who is providing your care? (select
all that apply) Logic: if answer B AND A or E please indicate error for inconsistent answer
Do not receive long COVID care from VA
VA long COVID program or post-COVID clinic
Primary care provider
One or more specialists
Have not heard of VA long COVID program or post-COVID clinic
3. How much do Long COVID symptoms still impact your activities of daily living (e.g.,
bathing, toileting, dressing, mobility)?
Completely
Greatly
Moderately
Slightly
Not At All
1
2
3
4
5
4. What COVID symptoms (ongoing, new, or worsening) are you struggling with the most in
your daily life? (select all that apply)
Logic: If answer with A AND B, C, D, or E, please indicate Error for inconsistent answer
None Logic: When selected skip to question 16
Fatigue
Brain Fog (Lack of focus or mental clarity)
Shortness of breath
Coughing
Other symptoms
5. Do you have someone (a paid or unpaid caregiver) who helps you with daily activities
because of ongoing, new, or worsening COVID symptoms?
No
Yes, but they are not enrolled in the VA Caregiver Support Program
Yes, and they are enrolled in the VA Caregiver Support Program
Other
6. In what ways have COVID symptoms (ongoing, new, or worsening) specifically
impacted your employment? (select all that apply)
Logic – if answer with A AND C, D, or E please indicate error for inconsistent answer.
I am retired
No impact on my employment
It has hurt my ability to find job
My job performance has suffered
It’s caused me to miss work
7. Which of the following types of support do you need to manage your Long COVID
symptoms? (select all that apply)
Logic – if answer with A AND B, C, or D, please indicate Error for inconsistent answer
None at this time
Medical care (e.g., access to specialists, treatments, procedures, mental health counseling, etc.)
Support (e.g., medical equipment, caregivers support, spiritual support, COVID information, etc.)
Other
8. Which of the following equipment would help with your Long COVID symptoms?
Logic – if answer with A AND B, C, or D, please indicate Error for inconsistent answer
Don’t need this kind of equipment
Portable oxygen units
Mobility assistance (e.g., walker, cane, wheelchair, shower chair, bedside commode)
Other
9. When you consider your options for your care, please rank your preference with 1
being most preferred. Click on the down arrow beside each option
Video telehealth visit
Phone visit
In-person visit
No preference
10. All my VA healthcare providers seem informed and up-to-date about all of my
ongoing COVID care.
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
2
3
4
5
1
Not Applicable
(N/A)
11. Overall, I am satisfied with the in-person COVID follow-up care I receive(d) from VA.
Have not had
in-person
Strongly
Strongly
Neither
Disagree
Agree
follow-up from
Disagree
Agree
VA
1
2
3
4
5
12. Overall, I am satisfied with the telehealth (video and telephone) COVID follow-up
care I receive(d) from VA.
Have not had
telehealth
Strongly
Strongly
Neither
Disagree
Agree
follow-up from
Disagree
Agree
VA
1
2
3
4
5
13. Overall, I am satisfied with my Long COVID care.
Strongly Disagree
Disagree
Neither
Agree
Strongly
Agree
1
2
3
4
5
Required
14. I trust VA to provide healthcare for my Long COVID needs.
Strongly Disagree
Disagree
Neither
Agree
Strongly
Agree
1
2
3
4
5
15. Please provide us with any additional comments regarding your VA care for your Long
COVID symptoms or needs. 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
Finish
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. Your contact information and response may be referred to the Veterans Crisis Line if an automated
review indicates your response may be concerning. The Veterans Crisis Line may contact you for follow up as a result of
that referral. 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. This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. 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
5 minutes 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
Long COVID
V1 DRAFT
12/20/2022
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: 02/28/2026
Estimated Burden:5 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.
We are asking for this information so that you can provide compliments, recommendations, or concerns to VA. By filling out
this survey, you are authorizing VA database access to retrieve Veteran contact information to follow up with you accordingly
for purposes of service recovery, potential crisis, or to learn more about feedback you have shared regarding your
experience with VA. Your contact information and response may be referred to the Veterans Crisis Line if an automated
review indicates your response may be concerning. The Veterans Crisis Line may contact you for follow up as a result of
that referral. 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. This information is collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. 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
5 minutes 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 | 2023-02-10 |
| File Created | 2023-02-10 |