Pilot Study for the National Survey of Veterans (NSV), Active Duty Service Members, Activated National Guard and Reserve Members, Family Members and Survivors

National Survey
of Veterans

US Department of Veterans Affairs
OMB# XXXX-XXXX
Expiration Date: XXXXXXXXXX

This questionnaire is part of the National Survey of Veterans, a study sponsored by the
U.S. Department of Veterans (VA). Please have the military veteran in the household
fill out the enclosed questionnaire, which covers the awareness of services and
knowledge of how to access services provided by the VA.
Your participation is voluntary, but your response to the survey is very important to the
success of this study.

VA may not conduct, sponsor, or require the respondent to respond to this collection of information unless it displays a valid OMB
Control Number. All responses to this collection are voluntary. Public reporting burden for this collection of information is estimated
to average 5 minutes per response, including the time necessary for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of information. Failure to furnish the
requested information will have no adverse effect on any VA benefits to which you may be entitled.
The information you supply will be confidential and protected by the Privacy Act of 1974 (5 U.S.C. 522a) and the VA's confidentiality
statute (38 U.S.C. 5701) as implemented by 38 CFR 1.526(a) and 38 CFR 1.576(b). Disclosure of information involves releases of
statistical data and other non-identifying data for the improvement of services with the VA benefits processing system and for
associated administrative purposes.

PART 1. MILITARY SERVICE
We'd like to start with some questions about your military service.

1.

Have you ever served on active duty in the U.S. Armed Forces?
Yes, now on active duty
Yes, on active duty in the past, but not now

Go to Question 3

No, never on active duty except for initial/basic training
No, never served in the U.S. Armed Forces

2.

This survey is intended for individuals who served on Active Duty, but are no longer
serving. Please return the survey in the enclosed pre-paid return envelope. Thank
you very much for your help!

3.

Was any of this active duty service part of a mobilization or activation while serving
as a member of the National Guard or Reserve?
Never served on active duty as a member of the
National Guard/Reserve Component

Go to Question 5

Yes, served on active duty while in the
National Guard/Reserve Component

4.

Are you currently a member of the Reserves or National Guard?
YES
NO

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5.

While you were on active duty, which period(s) did you serve?
Please check all that apply.
Period of Service
November 1941 or earlier
January 1947 to June 1950
February 1955 to February 1961
World War II (December 1941 to December 1946)

Go to Question 8

Korean War (July 1950 to January 1955)
March 1961 to July 1964
Vietnam era (August 1964 to April 1975)
May 1975 to August 1980
September 1980 to July 1990
August 1990 to August 2001 (including Persian Gulf War)
September 2001 or later

6.

Have you ever been deployed as part of Operation Enduring Freedom (OEF) / Operation
Iraqi Freedom (OIF) / Operation Noble Eagle (ONE)?
YES
NO

7.

Go to Question 8

Please mark deployments as part of, or in support of, OIF/OEF.
Please check all that apply.
Deployed to IRAQ for OIF/OEF
Deployed to Afghanistan for OIF/OEF
Deployed to some other middle Eastern nation (e.g., Kuwait) for OIF/OEF
Deployed CONUS as part of Operation Noble Eagle (ONE) support
Deployed OCONUS as part of Operation Noble Eagle (ONE) support
Deployed to some other location (please specify

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)

PART 2. VA BENEFITS AND SERVICES
Next, we'd like to ask you about VA benefits and services.
8.

Are you currently, or have you ever been, enrolled in VA health care?
YES
NO
DON'T KNOW

9.

Please indicate how much you agree or disagree with the following statements
regarding the Veterans benefits provided by VA.
Strongly
agree

a. I thoroughly understand the Veterans
benefits that are available to me
b. I thoroughly understand the Veterans
health care benefits I'm entitled to
c. I thoroughly understand the Veterans
burial benefits available to me
d. I thoroughly understand the Veterans
education and training benefits I'm
entitled to from the VA
e. I thoroughly understand the Veterans
life insurance benefits I'm entitled to
from the VA
f. I thoroughly understand the Veterans
Home Loan Guaranty benefits I'm
entitled to

3

Agree

Neither
agree nor
disagree

Disagree

Strongly
disagree

Does
not apply

10.

Below is a list of topics about VA benefits and services. Please indicate whether you
have looked for information on these in the past 12 months.
YES

NO
Eligibility for VA health care
VA health care facility locations
VA life insurance
VA home loans
VA education and training
VA vocational rehabilitation
VA burial and memorial benefits
VA disability compensation and pension
VA benefits for dependents and survivors
VA prescription benefits

11.

While still on active duty, did you attend any of the transition assistance workshops
known as the Transition Assistance Program (TAP) or the Disabled Transition Assistance
Program (DTAP)?
YES
NO

12.

In the past year have you used any of the following sources to get information about
VA benefits and services?
YES

NO
a. The VA web site
b. A veteran service organization (e.g., American Legion, VFW, etc.)
c. Your local VA office
d. A VA health care facility
e. A VA Toll Free Help Line
f. The VA Veterans Benefits Handbook
g. Other (please specify)

13.

By what method would you most prefer to get answers to your VA questions?
Mail
Telephone
E-mail
Face to face (in person)
Internet
Other (please specify)

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PART 3. DEMOGRAPHIC INFORMATION
Finally, we'd like to ask you a few questions about yourself.
14.

What is your gender?
MALE
FEMALE

15.

What is your year of birth?

YEAR
16.

Are you of Hispanic, Latino, or Spanish origin?
No, not of Hispanic, Latino, or Spanish origin
Yes, Cuban
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, another Hispanic, Latino, or Spanish origin
Print origin, for example, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran,
Spaniard, and so on. Print origin here:

17.

What is your race? (Mark all that apply)
White
Black, African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Other Asian (for example, Hmong, Laotian, Thai, Pakistani, Cambodian, and so on)
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander (for example, Fijian, Tongan, and so on)

Please go to next page
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18.

Please indicate whether your family received income (past 12 months) in any of the
categories listed below.
Please think about income from all members of this family who are 15 years of age or
older.
YES

DON'T
NO KNOW
a. Wages, salary, commissions, bonuses, or tips from all jobs
b. Self-employment income from own nonfarm businesses or farm
businesses, including proprietorships and partnerships
c. Interest, dividends, net rental income, royalty income, or income from
estates and trusts
d. Social Security or Railroad Retirement
e. Supplemental Security Income (SSI)
f. Any public assistance or welfare payments from the state or local
welfare office
g. Retirement, survivor, or disability pensions
h. Veterans' (VA) service-connected disability compensation payments
i. All other VA payments (e.g., VA education payments)
j. Any other sources of income received regularly such as unemployment
compensation, child support or alimony

19.

Which income range category represents the total combined income of all members of
this family during the past 12 months? (This includes income from all sources mentioned
in item 18 above)
LESS THAN $5,000

$30,000 TO $34,999

$5,000 TO $7,499

$35,000 TO $39,999

$7,500 TO $9,999

$40,000 TO $49,999

$10,000 TO $12,499

$50,000 TO $59,999

$12,500 TO $14,999

$60,000 TO $74,999

$15,000 TO $19,999

$75,000 TO $99,999

$20,000 TO $24,999

$100,000 TO $149,999

$25,000 TO $29,999

$150,000 TO MORE

Please return this questionnaire in the postage paid envelope.
Thank you very much for your help!

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