Member Satisfaction Survey

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

World Trade Center Health Program
State University of New York, Stony Brook

500 Commack Road. Suite 204, Commack, NY 11725 Tel. (631) 855-1200 Fax (631) 630-6297
173 Mineola Blvd, Suite 302, Mineola, NY 11501 Fax (516) 419-5919

Dear Member,

We invite you to take part in this brief survey and tell us about your experiences at the Long Island WTC Health
Program. It is very important to us that we are doing what we can to improve our services and make sure we
are meeting the needs of our 9/11 responders.
Your willingness to take part in this survey is greatly appreciated. We have enclosed a stamped, pre‐addressed
envelope for you to mail back to us. We kindly request this survey be mailed back within 2 weeks of receipt.

Thank you for your time,

Your Long Island Center of Excellence‐WTC Health Program.

Public reporting burden of this collection of information is estimated to average 10 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).

Page 1 of 4

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

Member Survey‐ March 2019

1) Have you been seen for a Monitoring Exam in the past 2 years?

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

2) In your opinion, why is the annual Monitoring Visit important to you? (check all that apply)








I want to monitor my health
I want to contribute to the Research Program
I need updated referrals to see my Specialist for my 9/11 certified conditions
I want to keep up to date on program changes and community events
I want to take advantage of free screenings to monitor potential issues
I don’t think it is important to come in for yearly monitoring
Other:

3) Have you been in for a Treatment Exam in the last year?

 Yes
 No
 N/A (not certified for WTC-related condition), please skip to Question #9!

4) Have you been assigned a Social Worker/Case Manager through the Program?
 Yes
 No
If Yes, how satisfied are you with our Case Management Program?
 Very Satisfied
 Satisfied
 Neutral
 Not Satisfied

5) Did you receive referrals to Specialists during your Monitoring Visit?

 Yes
 No
If Yes, how satisfied were you with the explanation of our healthcare network and how and when you
can go to a specialist for your WTC care?
 Very Satisfied
 Satisfied
 Neutral
 Not Satisfied

Page 2 of 4

6) Do you regularly see a Specialist within our network?
 Yes
 No
If Yes, how satisfied are you with their services?
 Very Satisfied
 Satisfied
 Neutral
 Not Satisfied

7) Have you received medications covered by the program in the last year?

 Yes
 No
If Yes, how satisfied are you with the ease of receiving your medications?
 Very Satisfied
 Satisfied
 Neutral
 Not Satisfied

8) Do you use Durable Medical Equipment (DME) for a certified condition?
 Yes
 No
If Yes, how satisfied are you with this service?

Very Satisfied

Satisfied

Neutral

Not Satisfied

9) Have you taken advantage of our Nutrition Services?

 Yes
 No
If Yes, how satisfied are you with this addition to our program?
 Very Satisfied
 Satisfied
 Neutral
 Not Satisfied

10) How likely are you to recommend the Long Island Clinical Center of Excellence to a fellow responder?





Very Likely
Likely
Neutral
Not likely

11) Would you like a Member Services Specialist to Contact you?
 Yes
If Yes, please complete below?

 No

Name:
Phone Number:
Best time to reach you:

Page 3 of 4

Additional Comments/Suggestions: __________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Page 4 of 4