VA Health Care Utilization Survey #1
Answers marked with a * are required.
1.
Do you live in the Lehigh Valley (Lehigh or Northampton County) of Pennsylvania?
*
Yes
No, but I live in one of the surrounding counties (Carbon, Monroe, Warren (NJ), Bucks, Montgomery, Berks, and Schuylkill).
No
Other (Please Specify)
2.
Did you perform federal, active duty service in the U.S. Military?
*
Yes
No
3.
Did you serve sometime after 7 October 2001 (the "Global War on Terrorism" period)?
*
Yes
No
4.
Are you still on active duty status?
*
Yes
No
Other (Please Specify)
5.
My age group is:
*
Under 18
18 to 34
35 to 54
55 to 64
65 to 74
75 or older
6.
Are you enrolled in the VA Health Care system (You signed up to use it.)?
*
Yes
No
7.
Is it your primary source of health care?
*
Yes
No, I never have used it.
No, I sometimes use it, but I mostly use another system or medical insurance (includes TRICARE).
No, I use TRICARE.
Undecided
Other (Please Specify)
8.
Are you drawing disability compensation or a pension from the VA (You receive a monthly check/deposit.)?
Yes
No
9.
Do you have a disability rating for a service-connected injury?
Yes
No
10.
My dependents use CHAMPVA (VA health care for dependents)?
Yes
No, but I AM rated permanently and totally disabled due to a service-connected disability.
No, because I AM NOT rated permanently and totally disabled due to a service-connected disability.
No, the question is not applicable because I have no dependents.
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