Attachment B - Recruiting Screener Questionnaire.docx

Office of the CTO at VA User Research Participant Recruiting Screener Questionnaire These questions allow us to better match you with specific feedback sessions. Questions with * are required. We will only use your address and phone number to coordinate your participation in the study and to provide your compensation.

The more information we have, the better we can match you with the most helpful feedback sessions. For the additional questions, please only answer questions you feel comfortable with.

Respondent burden: 5 minutes OMB Control #: 2900-0770 Expiration date:

Survey Disclaimer: 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.

1. Name * Email * Address * Street address Street address 2 City State Zip Phone (Type like this: 555.555.5555) *

Why do we ask for your address?

We ask for your address for several reasons. First, we try to ensure that we have geographical diversity among our participants. Second, in the unlikely event that you experience a medical or mental health emergency during a research session, we can use your address on file to ensure that we can direct resources to you.

2. Would you describe your primary residence as urban or rural?

According to the U.S. Census, you live in an urban area if there are more than 2,500 people in the region where you live.

Rural Urban

Why do we ask this question?

A priority for VA is making sure that Veterans who live in rural areas enjoy easy access to their VA services and benefits. By researching with Veterans who live in both rural and urban areas, we ensure that the applications and services we build serve our geographically diverse Veteran and caregiver population.

3. Are you a Veteran, Veteran's family member, Veteran's caregiver, or service member? (Check all that apply) *

a. Veteran

b. Veteran's family member (such as a spouse or dependent)

c. Veteran's caregiver

d. Service member

Why do we ask this question?

Frequently we conduct feedback sessions with participants who are in different stages of their service career, as well as potential or current recipients of VA benefits. We ask this question to ensure that we conduct feedback sessions with representative sample populations.

4. Which of these best describes you? (Check all that apply):

a. Woman

b. Man

c. Cisgender

d. Non-binary

e. Transgender

f. Two-spirit (Indigenous only)

g. Prefer to self describe

h. Prefer not to answer

VA is committed to gender equity. It is important to us that the services and applications we design meet the needs of all Veterans, caregivers, dependents, and service members. We ask this question to ensure that we conduct Veteran-feedback sessions with representative populations.

5. Which of these best describes you? (Check all that apply) American Indian or Alaska Native Asian Black or African American Hispanic, Latino, or Spanish origin Native Hawaiian or other Pacific Islander White or Caucasian Prefer to self-describe Prefer not to answer

VA is committed to diversity and inclusion. It is important to us that the services and applications we design meet the needs of all Veterans, caregivers, dependents, and service members. We ask this question to ensure that we conduct Veteran-feedback sessions with representative populations.

6. In what year were you born?

It is important to us that the services and applications we design meet the needs of all Veterans, caregivers, dependents, and service members, regardless of their age. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations.

7. Which assistive technologies do you use on a daily or near-daily basis? Mark ALL that apply. If the one(s) you are using is not listed, please select "Other" and list all that you use there.

I don’t use any assistive technology Font resizing/larger Screen magnification or zoom Screen reader (e.g. JAWS, NVDA, VoiceOver, ChromeVox) Braille terminal Voice control / speech recognition software (e.g. Dragon, Siri, Google home, Google assistant, Cortana) Speech generating device Speech to text (I.e. Dragon Naturally Speaking, Google Doc Voice Typing, Windows Speech Recognition) High contrast mode or browser color preferences Alternative keyboard Alternative mouse or stylus Keyboard only navigation (no mouse usage) Switch access, head pointer, or eye tracking Joystick Teletypewriter or telecommunication device for the deaf (TTY) Closed captions Amplified telephone Hearing aid Cochlear implant Cane, walker, guide animal, or other walking aid Wheelchair Prosthetics Wearable tech (not prosthetic) Augmentive and alternative communication device Sign language interpreter Speech-to-speech transliterator Visual aids Writing on paper Typing with phone or tablet and showing it to others Caregiver Other I am not sure

It is important to us that the services and applications we design meet the needs of all Veterans, caregivers, dependents, and service members. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations.

8. What is the highest level of education you have completed?

None 1st-4th grade 5th-6th grade 7th-8th grade 9th grade 10th grade 11th grade High school graduate or equivalent Some college, no college degree Associate’s degree, occupational Associate’s degree, academic Bachelor’s degree Master’s degree Professional degree Doctoral degree

Why do we ask this question?

It is important to us that the services and applications we design meet the needs of all Veterans, caregivers, dependents, and service members. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations. Additionally, we occasionally do Veteran-feedback research related to education benefits, and this question helps us match potential participants to studies.

9. Which branch(es) of the military are/were you in? (Check all that apply) Air Force Army Coast Guard Marine Corps Navy Space Force Public Health Corps Other I am a caregiver/dependent

Why do we ask this question?

It is important to us that the services and applications we build meet the needs of all Veterans and service members across all branches of service. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations.

10. In what year did you join the service?

11. Are you still active duty?

Yes No In the Reserves

12. What year did you get out of the service? {year} (conditional – if Yes, active duty, do not ask 12).

Why do we ask these questions?

It is important to us that the services and applications we build meet the needs of all Veterans and service members from different service eras and experiences. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations. Additionally, we conduct periodic research studies to learn more about benefits for specific service eras, or for specific populations (such as transitioning active duty service members. This question helps us target our research sample.

13. Were you deployed overseas during your service?

Yes No Prefer not to answer

14. Did you serve in a combat zone?

Yes No Prefer not to answer

Why do we ask these questions?

We periodically conduct Veteran feedback studies with specific service history requirements. These questions help us identify the right participants for each study.

15. Do you currently work for, or have you ever worked for VA or for a Veteran Service Organization? (Check all that apply) No Yes, I currently work for the VA Yes, I currently work for a VSO I used to work for the VA I used to work for a VSO

We understand that many Veterans work at the VA or with VSOs, and through their work have additional familiarity with certain types of VA benefits. This question helps us identify the best participants for each Veteran feedback session.

16. Do you currently receive any VA benefits or services?

Yes No I do not know.

17. (Conditional, if yes to 16): Which VA benefits or services do you have experience with? (Check all that apply - optional) Health care benefits Education & career services; such as such as GI Bill Disability benefits; such as claims & appeals Housing benefits; such as adaptive housing, home loans, homelessness services Pension benefits Life Insurance Memorial benefits Other I do not know.

18. (Conditional, If yes to 16): In what year did you receive your first VA benefit? Your best estimate is acceptable.

19. (Conditional, If yes to 16) How did you apply for your first VA benefit?

On my own, on paper On my own, online On my own, in person With the help of a VSO With the help of a transition service officer at Department of Defense With the help of a fellow Veteran Other

Why do we ask these questions?

Occasionally in our Veteran feedback studies, we are seeking to talk to participants who have not yet applied for benefits, who receive certain types of benefits, who applied during a specific timeframe, or who applied with or without assistance. These questions help us match participants for each study.

20. How often do you go online to access VA benefits and services? Select the response that most closely describes your situation.

Never About once a year, or less About once a quarter (every 3-4 months) About once a month A few times a month (e.g. every 2 weeks) About once a week A few times a week (e.g. every other day) About once a day

It is important to us that the services and applications we build meet the needs of all Veterans and service members across a spectrum of digital literacy. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations.

21. In which languages do you feel comfortable reading content? Check all that apply.

English Spanish Chinese Tagalog Vietnamese French Haitian Creole Korean German Arabic Other Asian African Other not listed

It is important to us that the services and applications we build meet the needs of all Veterans and service members across a spectrum of English proficiency. We ask this question to ensure that we conduct Veteran-feedback sessions with representative sample populations.