Form 0920-0953 WTC Mt. Sinai Medical Center Annual Survey

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

Dear Member:
We invite you to take part in a brief survey about your experiences at the World Trade
Center Health Program Clinical Center of Excellence at Mount Sinai (WTC CCE at
Mount Sinai). Thank you for taking the time to share your input; your answers are
completely anonymous. Your feedback is greatly appreciated as we work to improve
our services for all of our patients.
Throughout the year, we received excellent feedback from WTC Health Program
members about how we can improve our performance and what members find most
valuable. It’s important to us that we do what we can to improve our services and
meet your needs and the needs of your fellow 9/11 responders.
Thank you for being a member of the WTC Health Program and for attending your
visits at the Mount Sinai Clinical Center of Excellence.
Sincerely,

Your WTC CCE at Mount Sinai Team

Annual SurvEy
Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2021
1.

Have you been seen for a Medical Monitoring Exam in the

5. Is MyChart and its features (results letters, submitting

past two years?

medication requests, filling out forms electronically, and

Yes o
No
o

being able to contact the provider) helpful?
I use MyChart and find it helpful
o
I do not have MyChart; I do not know how to sign
o

If no, what prevented you from coming in?
(check all that apply)
I don’t need medical care for 9/11-related health issues
o
My work/family schedule is too busy
o
Clinic hours/availability do not meet my needs
o
I had a poor experience in the past
o
I am too sick to attend appointments
o
I have problems getting to the clinic location
o
Other: __________________________________________

up (Please refer to the handout provided to learn
more about signing up and MyChart features)
I do not have MyChart and I am not interested
o
I have MyChart and I do not find it helpful
o
I do not know what MyChart is
o
6. I can reach the clinic staff easily if I have any questions
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o

________________________________________________
2. What is your preferred method of communication about
scheduling an appointment?
Please rate from 1-4 (1 is most preferred):
Phone Call

Please rate our facility:
Waiting room was comfortable and clean

Email

Yes o
No
o

Text Message

Exam room was comfortable and clean

Physical Mail

Yes o
No
o

Please list your ideal appointment time ___________
3. What is your preferred way of receiving updates about the
Program?
Please rate from 1-4 (1 is most preferred):
Email
Text Message
Physical Mail
Selikoff Centers Occupational Health Mobile App
4. Do you use the Selikoff Centers Occupational Health Mobile
App to find information about the WTC CCE at Mount Sinai?
Yes
o
No
o
I am not familiar with the app but would like to
o
download it*
I do not use mobile apps
o
*To download the mobile app: Search “Selikoff ” in the App Store or
Google Play Store
Page 1

7.

Front desk staff were friendly and helpful
Yes o
No
o
8. Please rate our Medical Support Staff (nurse administering
your questionnaire, medical assistant taking your blood,
doing the breathing test):
They listened to me
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o
They were friendly and helpful
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o

Please Turn Over

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

They were able to answer my questions
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o
9. Please rate the Social Worker who met with you:
My Social Worker listened to me and offered support
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o
Does not apply
o
My Social Worker explained information clearly
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o
Does not apply
o
10. Please rate the Provider who examined you

11. Have you been assigned a Patient Service Coordinator
(doctors’ or nurses’ assistant)/Nurse Case Manager
through the Program?
Yes o
No o
Not Sure
o
If Yes, how satisfied are you with your Patient
Service Coordinator/Nurse Case Manager?

o
o
o
o

Very Satisfied
Satisfied
Neutral
Not Satisfied

12. Many forms/questionnaires need to be filled out prior
to your exam in order to provide crucial information to
your care team. How can we improve the information
collection process for you?
________________________________________________
________________________________________________
________________________________________________
How can we improve your and other responders’

(Doctor or Nurse Practitioner)

experience?

My Provider listened to me:

________________________________________________

Strongly Agree
o
Agree
o
Neutral
o
Disagree
o
My Provider explained information clearly:
Strongly Agree
o
Agree
o
Neutral
o
Disagree
o

________________________________________________
________________________________________________
13. Would you like a Member Services Specialist to Contact
you to address any questions you may have?
Yes o
No
o
If Yes, please complete below?
Name: ________________________________________
Phone Number: ________________________________
Best time to reach you: __________________________

Page 2

Public reporting burden of this collection of information is estimated to average 15 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).