Questionnaire Text

Questionnaire form view entire document:  text  image
28.

a. Does this person have a VA service-connected disability rating?
[] Yes (such as 0%, 10%, 20%, 100%)
[] No - skip to question 29a
b. What is this person's service-connected disability rating?
[] 0 percent
[] 10 or 20 percent
[] 30 or 40 percent
[] 50 or 60 percent
[] 70 percent or higher
Questionnaire instructions view entire document:  text  image
Questions 7-48 are a continuation of the questions for each person. Questions 7-48 are a continuation of the questions for each person. (Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)

Answer person questions 19 through 48 if this person is 15 years old or over.

28a. Mark the "yes" box if the person has a Department of Veterans Affairs (VA) service-connected disability rating.