English version

Formed Approved

OMB No. 0920-0953

Exp. Date 12/31/2015

World Trade Center Health Program Member Feedback Questionnaire

In order to make sure that all members are receiving quality healthcare services, we need your feedback by completing this brief form. Your answers will help us improve the World Trade Center (WTC) Health Program for your benefit.

Please fill out this survey and return it in the enclosed self-addressed stamped envelope OR you can complete the survey online at www.cdc.gov/wtc/survey. Please only complete the survey once.

You do not need to put your name on the survey as all responses are anonymous. Thank you for your time.

1. When was the last time you visited the WTC Health Program for a monitoring exam or treatment? Circle the answer that best applies:

1……………………………..2………………………………3……………………………...4………………………………5

Within Within Within More Never

the last year the last 2 years the last 3 years than 3 years

2. If you have not visited the WTC Health Program in the past 2 years, please tell us why by checking ALL of the reasons that apply below:

__ I feel healthy

__ I am too ill

__ I am too busy

__ I am seeing my own Doctor – please explain why: __________________________________

__ WTC Health Program Clinic issues:

__ Hours are inconvenient:

Please explain what hours would work best for you _______________________

__ Location is inconvenient (hard to get there, no parking/public transportation, etc.)

Briefly explain the issue: ____________________________________________

__ Exam too long

__ Quality of Care: please explain concern: _________________________________

__ Language barriers: please explain: _______________________________________

__ Other (briefly explain): ________________________________________________

__ Other: ______________________________________________________________

3. If you have ever contacted the WTC Health Program call center (1-888-982-4748), how satisfied were you with your experience? Circle the answer that best applies:

1………………………………..2……………………………3……………………………...4………………………………5

Very Dissatisfied Neither Satisfied Satisfied Very

Dissatisfied or Dissatisfied Satisfied

Briefly explain your answer: ______________________________________________

Public reporting burden of this collection of information is estimated to average 10 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).

4. What do you think is the best way for members to receive the WTC Health Program Newsletter? Please check the answer that best applies.

__ Paper copy in the mail

__ Email

__ Website (www.cdc.gov/wtc/index.html)

5. Has your health changed as a result of the services you’ve received from the WTC Health Program? Circle the answer that best applies:

1………………………………..2……………………………3……………………………...4………………………………5

Much Somewhat No Change Somewhat Much

Worse Worse Improved Improved

6. Please review each of the benefits of the WTC Health Program listed below. Please rank each item individually on how important you think each benefit is to you using the following: 1 – Very Important; 2 – Important; 3 – Not Important; or 4 – No opinion.

__ Annual Monitoring __ Prescription Benefits

__ Physical Health Treatment __ Mental Health Treatment

__ Belonging to a Program that Understands my Unique Needs __ Benefits Counseling

7. Overall, how satisfied are you with the WTC Health Program? Circle the answer that best applies:

1……………………………..2………………………………3……………………………...4………………………………5

Very Dissatisfied Neither Satisfied Satisfied Very

Dissatisfied or Dissatisfied Satisfied

8. From which of the following do you receive care?

__ The Nationwide Provider Network (NPN) that is administered by Logistics Health Inc. (LHI)

__ A Clinical Center of Excellence (CCE) in the NYC metropolitan area. Please check the CCE that provides your care.

__ Fire Department of the City of New York (FDNY)

__ Mount Sinai School of Medicine (MSSM)

__ North Shore-LIJ

__ NYC Health and Hospitals Corporation (HHC) WTC Environmental Health Center

__ NYU School of Medicine

__ Rutgers, Robert Wood Johnson Medical School EOHSI

__ State University of New York, Stony Brook (SUNY)

9. Please use this space to provide any additional comments about your experience with the WTC Health Program, or to provide suggestions on how to improve your experience.

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