Attachment A
World Trade Center Health Program Member Questionnaire
Form Approved
OMB No. 0920-0953
Exp. Date 8/31/2021
World
Trade Center Health Program Member Questionnaire
Thank you for enrolling in the WTC Health Program and visiting our clinic. We appreciate you taking time to complete this survey. Your responses will help us understand the best ways to reach WTC responders like you, and to help them enroll in the Program so they can receive health monitoring and treatment benefits.
Did you belong to a union at the time of your 9/11 response work?
Yes
No
If yes, which one? ___(union/local)______________
If yes, did you hear about the WTC Health Program through the union?
Yes
No
Do you belong to a union now?
Yes
No
If yes, which one? ____(union/local)_____________
If yes, did you hear about the WTC Health Program through the union?
Yes
No
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).
How did you hear about the WTC Health Program? (Check all that apply.)
WTC Health Program representative or staff person
Family member or friend
Coworker
Employer
My doctor
My church or house of worship
Health fair
Union meeting
Precinct meeting
Community event
WTC Health Program web site (www.cdc.gov/wtc)
New York City’s 9/11 Health web site (part of www.nyc.gov)
Program brochure, flyer or palm card
WTC Health Registry’s Treatment Referral Program (phone call or letter)
Bus or subway advertisement
Other advertisement
Social networking web site (such as Facebook, Twitter, Instagram, etc.)
News media (Story in a newspaper, on TV, radio, or news Web site)
9/11 Environmental Action
FealGood Foundation
International Association of Fire Fighters (IAFF)
New York Committee for Occupational Safety and Health (NYCOSH)
Single Stop USA
Tuesday’s Children
Voices of September 11th
Other [Please specify: _____________________________________]
I don’t remember.
What were the reasons you decided to enroll in the WTC Health Program? (Check all that apply.)
Comprehensive monitoring exams
Free medical services
Reputation of the centers offering services
My doctor referred me
I was concerned about my health
I think I have a health condition that might be related to 9/11
I want to make sure that I don’t have any health problems related to 9/11
I have been having mental health problems related to my work after 9/11
My family is concerned about my health.
To get help in applying for 9/11 related benefits.
My friend or coworker participates in the program and encouraged me to participate.
Other__________________________________________________________________
After you found out about this program, how long did you wait to enroll??
0 – 3 months
3 – 6 months
6 – 9 months
9 months – a year
More than a year
If you waited to enroll in the program, what were the reasons you waited? (Check all that apply.)
I looked for information about the program and couldn’t find anything about enrolling
I didn’t have any symptoms so I didn’t think I needed to enroll
I didn’t have time to enroll before now
I had a work conflict
I wasn’t aware of the benefits of the program until now
I was seeing my own doctor
I didn’t think the services were available near my home
I didn’t think my symptoms/conditions were related to my 9/11 exposure
I didn’t know the program was still open to new enrollees
Other: _________________________________________
How satisfied were you with the enrollment process for the WTC Health Program?
Very satisfied
Somewhat satisfied
Satisfied
Somewhat dissatisfied
Very dissatisfied
Did you have any of the following difficulties with the enrollment process? (Check all that apply.)
Too confusing/hard to understand
I had trouble finding the appropriate documentation
The form was too long
I needed help to complete the form, but couldn’t get it
The form was not available in the language I needed
I waited a long time to find out I was accepted
I had to resubmit my application
Other_______________________________________
Did you get any help when you were enrolling in the program?
No
Yes
If yes, who helped you?
Someone from my union
Staff person from WTC Health Program
Staff person from another organization
Coworker
Family member or friend
What did this person/organization do to help you? (Check all that apply.)
Helped me find documentation showing I performed 9/11 response work.
Helped me fill out the enrollment form.
Explained to me what the questions on the form meant.
Told me how to submit my application (by mail or fax).
Other__________________________________________________
Did you have any difficulty with scheduling today’s appointment?
Yes
No
If so, what difficulties did you experience? (Check all that apply.)
I called many times before getting through to someone or getting a call back
I called many times and was not called back
The available times were not convenient for me
I was given an appointment many weeks/months away
Other: ________________________________________
How would you like to receive information from the WTC Health Program? (Check all that apply.)
Mail (Letters, newsletters)
Website
Text message
Community events
Other ___________________
Do you use the following social media web sites? (Check all that apply.)
We ask this question because we would like to explore new ways to get program information out, and we are aware that more and more 9/11 workers and volunteers are using social media to communicate.
Tumblr
Wikipedia
Other: ____________________
Thank you so much for your feedback.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Lok, Annie |
File Modified | 0000-00-00 |
File Created | 2021-01-20 |