Form VSDHF Engagement S VSDHF Engagement S VSDHF Engagement Survey Wireframe

OMB Number: 2900-0876

Expiration: 2/28/2026

Estimated Burden: 5 minutes

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: Dial 988 (Press 1) or 1 (800) 273-8255 (Press 1), text 838255, or visit 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/.

Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to [email protected]. VA will not disclose your personal information to third parties outside VA without your consent or when immediately responding to an expressed concern or need for immediate information or resources.

As a community partner, the Veteran Social Determinants of Health Framework (VSDHF) Integrated Project Team (IPT) is conducting a survey and welcome your input and feedback.

This voluntary survey should take approximately 5 minutes to complete.

1. Does your organization currently screen for social determinants of health, namely: housing, transportation, food security, utilities, and interpersonal violence?

Yes

No

Logic: If #1 is Yes, then show #2

2. What current screening tool/ questions do you use?

(Free text box)

Logic: If #1 is Yes, then show #3

3. How would you rate your satisfaction with your organization’s screening tool for social determinants of health

Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied

4. Please share what data infrastructure system you have in place to receive and send data to medical facilities, on social determinants for health. For example, do you use FindHelp or UniteUs?

(Free text box)

5. How would you rate your satisfaction with that data infrastructure system?

Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Not Applicable

6. Does your organization track metrics after a referral is made to your organization, such as veteran satisfaction for services delivered by your organization? If so, please share how this is collected.

(Free text box)

7. How would you rate your general satisfaction with those metrics.

Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Not Applicable

8. Is there any other information you would like to share with us?

(Free text box)

Logic: Required

9. I trust VA to support individual Veteran social determinants of health through internal VA programs in conjunction with community partnerships.

Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

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.