WTCHP Brief Demographic Survey

WTCHP Survey
The World Trade Center Health Program: Impact Assessment and Strategic Planning for
Translational Research
Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20xx
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-xxxx).

Please provide the following demographic information (this will be aggregated and kept private):
1.

Year of Birth:

2.

Sex:
Male
Female

3.

Hispanic/Latino Ethnicity:
Yes
No
Don't know/not sure

4.

Race (select all that apply):
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

5.

WTCHP role (select all that apply):
Funder/NIOSH staff
Researcher—WTCHP Health Registry or WTCHP-supported Principal Investigator

Research user—Clinician or leadership from WTC Centers of Excellence or Data Center
Other, please specify

6.

If you are a WTCHP member, are you a:
General Responder
FDNY Responder
Survivor
N/A

7.

If you are a clinician, what is your specialty?

8.

Number of years that you've been involved with the WTCHP: