Va Form 0928d - National Veterans Summer Sports Clinic Media And News Release Questionnaire - 2012
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1
2ATHLETE NUMBER-OFFICE USE ONLY
OMB Number: 2900-0759
Respondent Burden: 20 minutes
MEDIA AND NEWS RELEASE
QUESTIONNAIRE
2012 NATIONAL VETERANS SUMMER SPORTS CLINIC
PRIVACY ACT: VA is asking you to provide the information on this form under USC, Chapter 5, Section 521 and Chapter 17, Section 1710. VA
may disclose the information that you put on this form as permitted by law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices identified as 121VA19 “National Patient Databases - VA”. Providing the requested information is
voluntary.
RESPONDENT BURDEN: The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond
to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this
application will average 20 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the forms.
All participants must complete questions 1-15, whether or not you wish to have a news release. If you would like a news release posted
on the Clinic's website about your participation this year, you must fill out this form completely. Our Hometown News program
promotes publicity about the Clinic by posting an individual news release for every veteran who wants one on the website during the
week of the Clinic. The releases may be found at: In order to prepare your news release, we must
have all needed information in advance. We cannot gather this information during the Clinic. If you have any questions, please call VA
Public Affairs at (734) 845-5059.
NAME (Last, First, MI)
DATE OF BIRTH
E-MAIL ADDRESS
1. PLEASE CONFIRM YOUR BRANCH OF SERVICE
AIR FORCE
ARMY
COAST GUARD
MARINE CORPS
NAVY
NATIONAL GUARD
OTHER (Please specify)
2. IF YOU ARE A PEACETIME VETERAN, WHERE AND WHEN DID YOU SERVE?
3. DID YOU SERVE IN COMBAT IN ANY OF THE FOLLOWING CONFLICTS?
WWII
KOREA
VIETNAM
THE GULF WAR
AFGHANISTAN
IRAQ
OTHER (Please specify)
4. IS YOUR INJURY OR ILLNESS COMBAT
5. WHAT DID YOU DO IN THE SERVICE?
6. ARE YOU CURRENTLY ON ACTIVE DUTY
RELATED? (Resulting from actual service in combat)
WITH ANY BRANCH OF THE MILITARY?
YES
NO
YES
NO
7. HOW WERE YOU INJURED?
8. WERE YOU EVER HELD AS A POW? (If yes, where)
YES
NO
9. ARE YOU A VIETNAM ERA (NON-COMBAT) VETERAN?
YES
NO
10. UNDER WHICH GENERAL CONDITION DOES YOUR DIAGNOSIS FALL?
PARAPLEGIC
AMPUTEE
STROKE
QUADRIPLEGIC
RIGHT LEG
AK
OR
BK
OTHER NEUROLOGICAL INJURY OR DISEASE
MULTIPLE SCLEROSIS
LEFT LEG
AK
BK
HIP/KNEE REPLACEMENT
OR
BRAIN INJURY
OTHER AMPUTATION
SEVERE ARTHRITIS
VISUALLY IMPAIRED
BURN INJURY
LEGALLY BLIND
TOTALLY BLIND
OTHER DIAGNOSIS (Describe in simple language, not medical terms)
11. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
PVA
DAV
VFW
AMERICAN LEGION
AMVETS
MOPH
OTHER
12. WHAT IS YOUR PRIMARY VA MEDICAL CENTER (OR MILITARY HOSPITAL) (City, State)
0928d
VA FORM
Page 1 of 2
MAR 2012
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