Member Questionnaire - English

Dear Program Member,

Thank you for participating in the World Trade Center Health Program Clinical Center of Excellence at the Icahn School of Medicine at Mount Sinai.

In an effort to assess the needs of our members, particularly those who reside outside of Manhattan, we are asking members of our program to complete a brief questionnaire. Your responses will provide valuable information about potential barriers to accessing care at the WTC Health Program.

We ask that you complete this survey and return it to us during your clinic visit today.

Thank you again for your time, and continued participation in our program.

World Trade Center Health Program

Clinical Center of Excellence

Icahn School of Medicine at Mount Sinai

Form Approved

OMB No. 0920-0953

Exp. Date 8/31/2021

Members Questionnaire

1. Please circle the location of your current home address:

1. Staten Island

2. Brooklyn

3. Bronx

4. Queens

5. Manhattan

6. New Jersey

7. Connecticut

8. Other Area

2. Please circle the response that best describes what, if any, barriers you experience to attending appointments at the Mt. Sinai WTC Health Program in Manhattan:

	Not at all	Slightly	Moderately	Very Much
I have difficulty finding transportation to the clinic	1	2	3	4
The clinic is too far away	1	2	3	4
I have to pay more than I can afford to travel to the clinic	1	2	3	4
The clinic hours conflict with my parenting responsibilities	1	2	3	4
The clinic hours conflict with my work schedule	1	2	3	4
My medical problems make traveling to appointments at the clinic difficult	1	2	3	4

3. Please circle the best estimate of the costs associated with traveling to and from the Manhattan Mt. Sinai WTC Clinic (including parking, tolls, etc) per trip

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).

0-10 dollars

10-20 dollars

20-40 dollars

40 or more dollars

4. In your opinion, would you be more likely to attend regular WTC Health Program appointments if you could receive them closer to your home? Please circle one option:

Extremely Unlikely Unlikely Neutral Likely Extremely Likely