World Trade Center Health Program Member Feedback Questi

World Trade Center Health Program
Member Feedback Questionnaire

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

WTC Health Program
Our records show that you are a member of the WTC Health Program.
1. How long ago did you become a member of the Program?
 Less than 1 year ago
 1-2 years ago
 Over 2 years ago
 I am a member but I don’t know
 I wasn’t aware I am a member
If you would like more information about your membership in the WTC Health Program, provide
your name and a staff member will contact you, or call us at 1-888-982-4748.
Name:___________________________

Phone Number:__________________

2. Are you a Responder or a Survivor?
 Responder

Survivor

 Do not know

3. Overall, how satisfied are you with the WTC Health Program?
(Circle the answer that best applies)

Would you like to provide any comments about your answer to question #3? _______________
_____________________________________________________________________________

The Nationwide Provider Network (NPN)
Please answer the following questions about the care received through the Nationwide Provider
Network. Please do not include care received outside of the Program by your own doctors.
4. Are you aware that you are part of the Nationwide Provider Network?
 Yes

 No

 Do not know

If you would like more information about the NPN call us at 1-888-982-4748.
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).

1

5. When was the last time you visited your NPN Provider?
 Within the last 2 years (please go to question 7)
 More than 2 years ago (please go to question 6)
 Never (please go to question 6)
6. If you selected “More than 2 years” or “Never” please tell us why (Check all that apply)
 I am too ill.
 I feel healthy.
 I am too busy.
 I see my own doctor.
 I thought the Program had ended.
 Exam is too long.
Which exam? _______________________________________________________________
 NPN Provider’s schedule does not work for me.
What days/times would work? __________________________________________________
 I don’t like the location.
Please explain: _______________________________________________________________
 NPN Provider does not speak my language.
What language do you speak? __________________________________________________
 I have a concern about the quality of care.
What is your concern? ________________________________________________________
 Other: _____________________________________________________________________

Care from the Nationwide Provider Network in the Last Two Years
The next questions are about your experience visiting your NPN Provider within the last two years. If
you have not visited in the last two years, please check here  and skip to question 9.
7. Please think about how difficult or easy it has been to access the care, tests, or treatment that
you have needed. In the last two years, the care, tests or treatment I needed were:
(Circle the answer that best applies)

2

8. On a scale of 0 to 10, where 0 is the worst health care possible and 10 is the best health care
possible, what number would you use to rate all your health care received through the WTC
Health Program Clinic in the last two years?
(Circle the answer that best applies)

Would you like to provide any comments about your answer to question #8? _______________
_____________________________________________________________________________

About You
9. In general, how would you rate your overall health?
 Excellent
 Very good
 Good
 Fair
 Poor
10. Think about your health before you joined the Program. Would you say that your current
health is:
 Much better than before you joined the Program
 A little better than before you joined the Program
 About the same
 A little worse than before you joined the Program
 Much worse than before you joined the Program
 Don’t know
11. What is your age? ___________
12. What is your gender?
 Male
 Female

3

Program Communications
The next questions are about communication you receive from the WTC Health Program.
13. What would you like to know about the WTC Health Program? (Check all that apply)
 Program benefits
 Program news
 Healthy living tips
 9/11 health research
 Member stories
 Programs similar to the WTC Health Program, such as the 9/11 Victim Compensation Fund
 Other: _____________________________________________________________________
14. Where would you like to receive the information listed in question 13? (Check all that apply)
 WTC Health Program website
 Printed materials at my NPN Provider’s office
 Through the mail
 Social media such as Facebook and Twitter
 Newsletter
 Email
 Text message
 Other: _____________________________________________________________________
15. Do you use the Member Handbook?
 Yes (Check all that apply)
 I use the paper version
 I use the online version
 No, I do not use it

 No, I didn’t know there was one*

*To use the online version or order a paper copy go to www.cdc.gov/wtc/memberhandbook.html

Please provide any additional comments about your experience with the WTC Health Program, or
suggestions on how we can better serve you.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
If you have questions or concerns about the Program or your NPN Provider, please call 1-888-982-4748
Monday-Friday from 9am to 5pm, Eastern time, send an email to wtc@cdc.gov, or leave your contact
information on the following line and a member services representative will contact you:
___________________________________________________________________________________

4