|
|
1.
Do you live in the Lehigh Valley (Lehigh or Northampton County) of Pennsylvania?
*
|
|
|
|
|
2.
Did you perform federal, active duty service in the U.S. Military?
*
|
|
|
|
|
3.
Did you serve sometime after 7 October 2001 (the "Global War on Terrorism" period)?
*
|
|
|
|
|
4.
Are you still on active duty status?
*
|
|
|
|
|
5.
My age group is:
*
|
|
|
|
|
6.
Are you enrolled in the VA Health Care system (You signed up to use it.)?
*
|
|
|
|
|
7.
Is it your primary source of health care?
*
|
|
|
|
|
8.
Are you drawing disability compensation or a pension from the VA (You receive a monthly check/deposit.)?
|
|
|
|
|
9.
Do you have a disability rating for a service-connected injury?
|
|
|
|
|
10.
My dependents use CHAMPVA (VA health care for dependents)?
|
|
|
|
|