Treatment Satisfaction Survey - English

Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2021

Thank you for your participation in the WTC Health Program at
NYUSOM Clinical Center of Excellence!

We would like your help in improving our CCE and being able to better serve our patients. Please help us by taking
a few minutes to tell us about your treatment visit. This survey is anonymous. We appreciate your insights and feedback.

Question:

When was your monitoring exam?
Month: ___________ Year:________

Question:

Which treatment provider(s) did you visit? Please check all that apply
¡
¡
¡
¡

Pulmonary
ENT
GI
Mental Health

¡
¡
¡
¡

Social Work
Neurology
Cardiology
Other:_____________________

Question:

What was the reason for your visit? Please check all that apply
¡
¡
¡
¡
¡

Physical health concerns
Mental health concerns
Social Services needs
Asked by family member
Centralizing your healthcare

¡
¡
¡
¡

Medication needs
Workers Compensation
Victims Compensation Fund
Other:_____________________

Question:

Question:

Were you referred to other specialty
for further follow-up?
Yes

Please indicate why the NYU CCE was the best
option for your care
_______________________________________
_______________________________________
_______________________________________
_______________________________________

No

Question:

Did you accept your treatment referral?

Question:

Will you continue to participate in the treatment
program?
Yes
No (Please tell us why)
____________________________________________
____________________________________________
____________________________________________

Yes

No

Question:

If you selected that you were ‘Somewhat Dissatisfied’,
‘Dissatisfied’ or ‘Very Dissatisfied’ with one or more
component of your examination, please tell us why:
____________________________________________
____________________________________________
____________________________________________
____________________________________________

Question:

Is there anything you would like for us to
improve on?
_______________________________________
_______________________________________
_______________________________________
_______________________________________

Thank you for your feedback! We value you as a member and will take your
input into consideration while continuing to provide you with care and
services in the future. You may contact our office, Monday – Friday, between
9am – 5pm, at (212) 263-7335 if you have any questions regarding your
care.
Public reporting burden of this collection of information is estimated to average 2 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).