Veterans Survey 2011

Please complete as much of the survey as applies.
Thank you for your help and cooperation.

If you would like to download a survey form and submit it offline, please use the following link:
Veteran Survey 2011 Forms



On-Line Form Instructions

Part 1. Background Information

E-Mail address: (if none leave blank)
Age:


My VA disability rating is:

Part 2. Survey

Note: All Fields in red must be filled in.

1. Please select your county from the list:

2. I am registered with or enrolled in programs with the Veterans Administration (eg. Healthcare, Disability, Education, Home Loan, etc):

Yes No

3. Please select your primary period of service/conflict:

4. Please select the VA Benefit(s) you are receiving: (Click the check box for all that apply)
Pension
Disablility
Education
Mental Health
Medical Treatment
Homeless Services
Prescription Drugs
VGLI Insurance
Home Loan Guarantee
None of the above
Other (Please specifiy)

5. Which of the Veterans services listed in 4 above are most important to you (pick the top three):

6. Which of the following Veterans services do you have knowledge of? (Click the check box for all that apply):

Service Connected Entitlement
Non-Service Connected Pension
Death (Widows) Pension
Waivers Excess Income
Health Care
Vocation Rehab/Education
Educational Assistance(not GI Bill)
Burial Benefit
VA Home Loan Guarantee
VGLI Insurance Program
Incarcerated Veterans
Miscellaneous Claims
Military Records/Corrections
Colorado Veterans Trust Fund Grants
General Information/Referral
Copies of VA Records

Note: The fields below only allow Letters, Numbers and Punctuation (Symbols eg. \*/$#@ are not allowed).

7. Do you know veterans who have not used Veterans Administration services?
Yes No

Do you have suggestions how we could reach them?
8. What Federal veterans' services do you need that are not being provided by the US Department of Veterans Affairs?


9. What State veterans' services do you need that are not being provided by the State Division of Veterans Affairs?

10. Have you used the services of your County Veterans Service Officer(s)?

Yes No
11. If Yes rate their service to you: (required response if you answered "Yes" to #10)
12. If Poor or Very Bad please explain:

13. Have you used the services of your State Veterans Service Officer located at the State Division of Veterans Affairs at Lowry?

Yes No
14. If Yes rate their service to you:(required response if you answered "Yes" to #13)
15. If Poor or Very Bad please explain:

16. Have you used the services of a Service Organization Veterans Service Officer? (eg. Legion, VFW, DAW, PVA, etc)

Yes No
17. If Yes rate their service to you:(required response if you answered "Yes" to #16)
18. If Poor or Very Bad please explain:

19. Have you received veterans related services from other agencies not identified above?

Yes No
20. If Yes please identify:
21. Do you have access to a computer?
Yes No
22. If so, are you aware of online VA services?
Yes No
23. Have you used online VA services?
Yes No
24. I am:
male
female
single
married
divorced
25. If you are currently using VA educational benefits, are you enrolled in:
College or University
Community College
Technical School
Online
Other (Please specifiy)
26. Please Add any other comments you would like to make:

Note: Giving us your contact information is OPTIONAL.

Last Name: First Name:
Address: street
City ZIP:

If you have questions about veterans services provided by the Veterans
Administration or by the Colorado Division of Veterans Affairs
please call: 303-284-6077 or e-mail vetinfo@dmva.state.co.us
Thank you for taking part in the survey.