Fillable Printable VA Form 0927d
Fillable Printable VA Form 0927d
VA Form 0927d
OMB Number: 2900-0759
Respondent Burden: 20 minutes
MEDIA AND NEWS RELEASE
QUESTIONNAIRE
NATIONAL VETERANS TEE TOURNAMENT
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 athletes must complete questions 1-11, whether or not you wish to have a news release. If you would like a news release posted on
the Tournament's website about your participation this year, you must fill out this form completely. Our Hometown News program
promotes publicity about the event by posting an individual news release for every Veteran who wants one on the Tournament's website
during the week of the event. The releases may be found on the Tournament's website, www.tee.va.gov
. In order to prepare your news
release, we must have all needed information in advance. We cannot gather this information during the Tournament. If you have any
questions, please call VA Public Affairs at (757) 660-5239.
NAME (Last, First, MI) DATE OF BIRTH TELEPHONE NUMBER (Include area code)
E-MAIL ADDRESS CELL PHONE NUMBER (Include area code)
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
IRAQ AFGHANISTAN
OTHER (Please specify)
4. WERE YOU EVER HELD AS A POW? (If yes, where)
YES NO
5. ARE YOU A VIETNAM ERA (NONCOMBAT) VETERAN?
YES NO
6. OF WHICH VETERANS SERVICE ORGANIZATIONS ARE YOU A MEMBER?
BVA PVA DAV VFW
AMERICAN LEGION AMVETS MOPH OTHER
7. WHAT IS YOUR PRIMARY DISABILITY/DIAGNOSIS?
VISUAL IMPAIRMENT LEGALLY BLIND
TOTALLY BLIND
SPINAL CORD INJURY (SCI)
- LEVEL
COMPLETE INCOMPLETE
PARAPLEGIC
QUADRIPLEGIC
MULTIPLE SCLEROSIS (MS)
HEAD INJURY
CVA WITH RESIDUAL
AMPUTEE
RIGHT LEG AK
OR
BK RIGHT ARM AE
OR
BE
LEFT LEG AK
OR
BK LEFT ARM AE
OR
BE
OTHER
VA FORM
DEC 2010
0927d
8. HOW MANY PAST YEARS HAVE YOU
PARTICIPATED IN THE NATIONAL VETERANS TEE
TOURNAMENT?
9. DO YOU WANT US TO PREPARE A NEWS RELEASE
ABOUT YOUR PARTICIPATION IN THIS EVENT?
YES NO
10. IF YOU MARKED "YES" TO A NEWS RELEASE IN QUESTION 9, PLEASE PROVIDE THE FOLLOWING
INFORMATION.
REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION: I
REQUEST AND AUTHORIZE THE DEPARTMENT OF VETERANS AFFAIRS TO RELEASE THE MEDICAL
INFORMATION CONTAINED ON THIS FORM FOR VA MEDIA PURPOSES. (If you checked this block, please check
one of the boxes below.)
I GIVE MY PERMISSION FOR MY PHONE NUMBER TO BE INCLUDED IN MY NEWS RELEASE POSTED
ON THE EVENTS' WEBSITE
I DO NOT WANT MY PHONE NUMBER LISTED ON MY NEWS RELEASE
11. PLEASE NOTE: WHETHER OR NOT YOU WANT A NEWS RELEASE, TOURNAMENT RESULTS WILL BE
POSTED ON THE TOURNAMENT WEBSITE BY PARTICIPANT NAME UNLESS YOU CHECK THE "NO" BOX HERE.
NO (Results will not be posted; sign below)
12. YOUR QUOTE: HOW DO YOU FEEL ABOUT THIS EVENT, WHY IS IT BENEFICIAL, AND WHAT WOULD YOU
TELL OTHER VETERANS ABOUT IT? (Quotes are used for newsletter stories, participant profiles, speeches, and other public
relations activities.)
SIGNATURE (You must sign here so we can comply with your
wishes)
DATE SIGNED
VA FORM 0927d, DEC 2010, page 2
