World Trade Center Health Program Member Questionnaire

Form Approved

OMB No. 0920-0953

Exp. Date 12/31/2015

World Trade Center Health Program Member Questionnaire

Thank you for enrolling in the WTC Health Program and visiting our clinic. We appreciate you taking time to complete this survey. Your responses will help us understand the best ways to reach WTC responders like you, and to help them enroll in the Program so they can receive health monitoring and treatment benefits.

Did you belong to a union at the time of your 9/11 response work?

• Yes

• No

If yes, which one? ___(union/local)______________

If yes, did you hear about the WTC Health Program through the union?

• Yes

• No

Do you belong to a union now?

• Yes

• No

If yes, which one? ____(union/local)_____________

If yes, did you hear about the WTC Health Program through the union?

• Yes

• No

Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

How did you hear about the WTC Health Program? (Check all that apply.)

• WTC Health Program representative or staff person

• Family member or friend

• Coworker

• Employer

• My doctor

• My church or house of worship

• Health fair

• Union meeting

• Precinct meeting

• Community event

• WTC Health Program web site (www.cdc.gov/wtc)

• New York City’s 9/11 Health web site (part of www.nyc.gov)

• Program brochure, flyer or palm card

• WTC Health Registry’s Treatment Referral Program (phone call or letter)

• Bus or subway advertisement

• Other advertisement

• Social networking web site (such as Facebook, Twitter, Instagram, etc.)

• News media (Story in a newspaper, on TV, radio, or news Web site)

• 9/11 Environmental Action

• District Council 37, AFSCME

• ICF (Inner City Fund)

• International Association of Fire Fighters (IAFF)

• New York Committee for Occupational Safety and Health (NYCOSH)

• Single Stop USA

• Tuesday’s Children

• Voices of September 11th

• Other [Please specify: _____________________________________]

• I don’t remember.

What were the reasons you decided to enroll in the WTC Health Program? (Check all that apply.)

• Comprehensive monitoring exams

• Free medical services

• Reputation of the centers offering services

• My doctor referred me

• I was concerned about my health

• I think I have a health condition that might be related to 9/11

• I want to make sure that I don’t have any health problems related to 9/11

• I have been having mental health problems related to my work after 9/11

• My family is concerned about my health.

• To get help in applying for 9/11 related benefits.

• My friend or coworker participates in the program and encouraged me to participate.

• Other__________________________________________________________________

After you found out about this program, how long did you wait to enroll??

• 0 – 3 months

• 3 – 6 months

• 6 – 9 months

• 9 months – a year

• More than a year

If you waited to enroll in the program, what were the reasons you waited? (Check all that apply.)

• I looked for information about the program and couldn’t find anything about enrolling

• I didn’t have any symptoms so I didn’t think I needed to enroll

• I didn’t have time to enroll before now

• I had a work conflict

• I wasn’t aware of the benefits of the program until now

• I was seeing my own doctor

• I didn’t think the services were available near my home

• I didn’t think my symptoms/conditions were related to my 9/11 exposure

• I didn’t know the program was still open to new enrollees

• Other: _________________________________________

How satisfied were you with the enrollment process for the WTC Health Program?

• Very satisfied

• Somewhat satisfied

• Satisfied

• Somewhat dissatisfied

• Very dissatisfied

Did you have any of the following difficulties with the enrollment process? (Check all that apply.)

• Too confusing/hard to understand

• I had trouble finding the appropriate documentation

• The form was too long

• I needed help to complete the form, but couldn’t get it

• The form was not available in the language I needed

• I waited a long time to find out I was accepted

• I had to resubmit my application

• Other_______________________________________

Did you get any help when you were enrolling in the program?

• No

• Yes

If yes, who helped you?

• Someone from my union

• Staff person from WTC Health Program

• Staff person from another organization

• Coworker

• Family member or friend

What did this person/organization do to help you? (Check all that apply.)

• Helped me find documentation showing I performed 9/11 response work.

• Helped me fill out the enrollment form.

• Explained to me what the questions on the form meant.

• Told me how to submit my application (by mail or fax).

• Other__________________________________________________

Did you have any difficulty with scheduling today’s appointment?

• Yes

• No

If so, what difficulties did you experience? (Check all that apply.)

• I called many times before getting through to someone or getting a call back

• I called many times and was not called back

• The available times were not convenient for me

• I was given an appointment many weeks/months away

• Other: ________________________________________

How would you like to receive information from the WTC Health Program? (Check all that apply.)

• Mail (Letters, newsletters)

• E-mail

• Website

• Text message

• Community events

• Other ___________________

Do you use the following social media web sites? (Check all that apply.)

We ask this question because we would like to explore new ways to get program information out, and we are aware that more and more 9/11 workers and volunteers are using social media to communicate.

• Facebook

• Twitter

• Instagram

• Tumblr

• Pinterest

• Wikipedia

• Other: ____________________

Thank you so much for your feedback.

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