36C10B19Q0067-004.docx

Digital Service at VA User Research Participant Recruiting Screener Questionnaire

Respondent burden: 5 minutes OMB Control #: 2900-0770 Expiration date: 09/30/2020 Survey Disclaimer [link: display lightbox with Survey Disclaimer][endnoteRef:1] [1: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 2900-0770. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Office of Information and Regulatory Affairs, Office of Management and Budget, Attn: VA Desk Officer; 725 17th St. NW, Washington, DC 20503 or sent through electronic mail to oira_submission@omb.eop.gov. Please refer to “OMB Control No. 2900-0770” in any correspondence.]

These questions allow us to better match you with specific feedback sessions. Only answer questions you feel comfortable with, but the more information we have the better our matches will be.

Personal Information

1. Name

· First name [text input]

· Last name [text input]

2. Email [text input]

3. Phone Number [number input]

4. Are you a Veteran, Veteran's family member, Veteran's caretaker, or Servicemember? (Check all that apply) [checkboxes]

· Veteran

· Veteran's family member

· Veteran's caretaker

· Servicemember

5. I identify my gender as: [radio buttons]

· Female

· Male

· Transgender

· Other

· Prefer not to answer

6. I identify as: (Check all that apply) [checkboxes]

· American Indian or Alaska Native

· Asian

· Hispanic, Latino, or Spanish Origin

· Black or African American

· Native Hawaiian or Other Pacific Islander

· White or Caucasian

· Other

· Prefer not to answer

7. Age [radio buttons]

· 18 – 24

· 25 – 34

· 35 – 44

· 45 – 54

· 55 – 64

· 65 – 74

· 75 or older

8. Highest level of education? [radio buttons]

· Some high school (no diploma)

· High school diploma or equivalent (for ex: GED)

· Associate’s degree / trade certificate / vocational training

· Some college (no degree)

· Bachelor's degree

· Master's degree

· Doctorate degree

9. Employment status and profession [radio buttons]

· Unemployed

· Employed full-time (30+ hours/week)

· Employed part-time (less than 30 hours/week)

· Self-employed

· Retired

10. What is your ZIP code. [number field; 5 digits]

11. How did you hear about the opportunity to participate in VA website research? [text field; maximum allowed: 200 character]

Service related information

12. Which branch(es) of the military are/were you in? (Check all that apply) [checkboxes]

· Air Force

· Army

· Coast Guard

· Marine Corps

· Navy

· Other

13. What year did you join the service? [number field; YYYY]

14. Are you still active duty? [radio buttons]

· Yes

· No [if selected, ask 15]

· In the reserves

15. [Conditional based on response to 14; no] What year did you get out of the service? [number field YYYY]

16. Did you serve in combat?

· Yes

· No

Experience with the VA

17. Have you ever worked for the VA or a Veteran Service Organization? (Check all that apply) [checkboxes]

· No

· Yes, work(ed) for the VA

· Yes, work(ed) for a VSO

18. Which VA benefits or services do you have any experience with? (Check all that apply) [checkboxes]

· Health care benefits (clinic, prescription refill, messaging) [if selected, ask 19]

· Education & career services (GI Bill, VR&E) [if selected, ask 20]

· Disability benefits (claims & appeals) [if selected, ask 21]

· Housing benefits (adaptive housing, home loans, homelessness services)

· Pension benefits

· Life insurance

· Burial benefits

· Other

· None

19. [Conditional based on response to 18; health care benefits] Which of the VA health benefits have you used or are you exploring? (Check all that apply) [checkboxes]

· VA health care coverage

· Prescription refill

· Secure messaging

· Downloading medical records

· Scheduling a doctor's appointment

· Assistance with specific health issues, such as mental health or vision care.

20. [Conditional based on response to 18; education & career services] Which of the VA education and career benefits have you used or are you exploring (Check all that apply) [checkboxes]

· GI Bill (Post 9/11, Montgomery)

· Vocational Rehabilitation & Employment (VR&E)

· Veterans’ Educational Assistance Program (VEAP)

· Small business certification

· Dependents' educational assistance

21. [Conditional based on response to 18; disability benefits] How far has your disability claim progressed? (Check all that apply) [checkboxes] [radio buttons]

· I am preparing my application

· I submitted a claim

· I received a rating

· I filed an appeal

· I gave up

· I prefer not to answer

22. Have you ever used or explored any other VA benefits? Please describe [text field; 100 words]

Internet access

23. How often do you go online to access VA benefits and services? [radio buttons]

· Never

· About once a year

· About once a month

· About once a week

· Daily

24. When you have questions about your VA benefits and services, where do you go to find answers? (Check all that apply) [checkboxes]

· I call my VSO

· I call my local VA center

· I look on VA.gov

· I look on Vets.gov

· I search online for them (e.g. Google, Bing)

· I ask other Veterans

· I look at Veteran forum

25. Any sources of help we missed? [text field]

26. How do you access the internet? (Check all that apply) [checkboxes]

· Smartphone

· Tablet

· Personal computer

· Public or shared computer

· Work computer

27. Any other devices we didn’t list here?

28. Do you use any assistive devices, such as screen readers or braille display, to access the internet? [radio buttons]

· No

· Yes [text field] image1.jpg