0920-0953 Participation in WTC Health Program at NYUSOM Clinical C

Formed 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 monitoring visit. This survey is anonymous. We appreciate your insights and
feedback.

Question:

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

Question:

What was the reason for your visit? Please check all that apply
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Physical health concerns
Mental health concerns
Maintaining annual check up
Asked by family member
Centralizing your healthcare


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Desire for Treatment Program
Workers Compensation
Victims Compensation Fund
Other:_____________________

Question:

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

Question:

After monitoring, were you referred
to Treatment and further follow-up?
Yes

No

Question:

Did you accept your treatment referral?
Yes

No

Question:

Will you continue to participate in your annual,
monitoring examinations?
Yes
No (Please tell us why)
____________________________________________
____________________________________________
____________________________________________

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).