The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit North American phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

CHALENG Request Form

If you are requesting a PDF copy of the CHALENG Survey or need to send in already completed CHALENG Surveys to be entered into the CHALENG database, please fill out the form below.

Please provide a point-of-contact e-mail. This e-mail will be used by us to send you the materials you need as well as a way for us to contact you if we have any questions:

* must provide value

VAMC or VA facility:

* must provide value

I am completing this form to:

* must provide value

Request the CHALENG Survey PDF to print out paper forms.

Notify NCHAV that my facility does not have the resources to enter the paper surveys that we have collected into the CHALENG database and will, therefore, be sending them to NCHAV. Please be advised that depending on NCHAV staff availability and resources, it may take 2 months or more before this data will be reflected on the CHALENG dashboard.

reset

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.