Form 0920-0953 Member Survey - 2018

Formed Approved
OMB No. 0920-0953
Exp. Date 7/31/2018

Dear Member,

We invite you to take part in this brief survey and tell us about your experiences at the Long Island WTC Health
Program. It is very important to us that we are doing what we can to improve our services and make sure we
are meeting the needs of our 9/11 responders.
Your willingness to take part in this survey is greatly appreciated. We have enclosed a stamped, pre- addressed
envelope for you to mail back to us. We kindly request that this survey is mailed back within 2 weeks of receipt.

Thank you for your time,

Your community at the Long Island Center of Excellence- WTC Health Program

Public reporting burden of this collection of information is estimated to average 5 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).

Formed Approved
OMB No. 0920-0953
Exp. Date 7/31/2018

Member Survey- March 2018
1) Have you been seen for a monitoring exam in the past 2 years?
 Yes
 No
1. If no, what has prevented you from coming in? (check all that apply)
 I don’t need medical care for 9/11 related health issues
 My work/family schedule is too busy
 The hours/availability of the clinic does not meet my needs
 I had a poor experience in the past
 I am too sick to attend appointments
 I have problems getting to the clinic location
 Other: ____________________________________________________
2) In your opinion, why is the annual monitoring visit important to you? (check all that apply)
 I want to monitor my health
 I want to contribute to the research program
 I need updated referrals to see my specialist for my 9/11 certified conditions
 I want to keep up to date on program changes and community events
 I want to take advantage of free screenings to monitor potential issues
 I do not think it is important to come in for yearly monitoring
 Other:
____________________________________________________
2) Have you been in for a treatment exam in the past year?
 Yes
 No
 N/A (not certified for WTC related condition), please skip to Question #5!
3) Do you regularly see a specialist within our network?
 Yes
 If yes, how satisfied are you with their services?
 Very satisfied
 Somewhat satisfied
 Neutral
 Somewhat satisfied
 Not satisfied
 Please provide details:____________________
 No

Formed Approved
OMB No. 0920-0953
Exp. Date 7/31/2018

4) Have you received medications covered by the program in the last year?
 Yes
 If yes, how satisfied are you with the ease of receiving your medications?
 Very satisfied
 Somewhat satisfied
 Neutral
 Somewhat not satisfied
 Not satisfied
 Please provide details:____________________
 No
5) In the past year, have you gone for a free screening? (colonoscopy, mammography, cervical cancer, lung
cancer screening)
 Yes, I received a referral for one of the above screenings and competed the visit
 Yes. I received a referral for one of the above screening but have not made an appointment
 No, I did not receive a referral for the one of the above screenings.
6) How likely are you to recommend the Long Island Clinical Center of Excellence to a fellow responder?
 Very likely
 Somewhat likely
 Neutral
 Somewhat not likely
 Not likely
 Please provide details:____________________
7) Do you have any additional comments/suggestions?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________________________
8) Would you like for someone from the program to contact you?


Yes
Name: __________________________________________
Phone Number: __________________________________
Best time to reach you: _____________________________