Form 0920-0891 Member Satisfaction Survey

World Trade Center (WTC) Health Program

As a member of the World Trade Center (WTC) Health Program, we value your opinion and feedback about the Program. The purpose of this survey is to learn about your experiences as a WTC Health Program member.

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?

q Less than 1 year ago

q 1-2 years ago

q Over 2 years ago

q I am a member, but I don’t know

q I wasn’t aware I am a member

2. Overall, how satisfied are you with the WTC Health Program as a whole? (Circle the answer that best applies, the WTC Health Program handles the following: application process, enrollment process, decisions on certification of your health condition(s), managing the call center, and managing pharmacy benefits.) Note: We will inquire about your experience with your assigned Clinical Center of Excellence (CCE) separately below.

2a. How satisfied are you with the following aspects of the WTC Health Program?

2b. Timeliness of the enrollment process

2c. Timeliness of the certification process

2d. Call Center Management

2e. Pharmacy Benefit Management

Would you like to provide any additional comments about your answer(s) to question #2?

3. In the last 6 months, how often did the WTC Health Program call center give you the information or help you needed?

1= Never

2= Sometimes

3= Usually

4= Always

5= N/A

6= No contact in the last 6 months

4. In the last 6 months, how often did the WTC Health Program call center staff treat you with courtesy and respect?

1= Never

2= Sometimes

3= Usually

4= Always

5= N/A

6= No contact in the last 6 months

Your WTC Health Program Provider

Please answer the following questions about the care received through your WTC Health Program assigned Provider’s office. Please do not include medical care not covered by the WTC Health Program.

1. Are you aware that you are assigned to a Clinical Center of Excellence (CCE) and/or our National Provider Network (NPN)

q Yes q No q Do not know

If Yes, please select the WTC Health Program clinic where you get care

1. Fire Department, City of New York (FDNY) Responder Clinic

2. NYC Health + Hospitals (H+H)

3. Icahn School of Medicine at Mount Sinai (MSSM)

4. North well Health

5. New York University School of Medicine (NYU)

6. Rutgers, The State University of New Jersey

7. State University of New York Stoney Brook (SUNY)

8. Logistics Health Incorporated (LHI)/National Provider Network (NPN)

2. When was the last time you visited your WTC Health Program Provider?

q Within the last 2 years

q More than 2 years ago

q Never

3. If you selected “More than 2 years” or “Never” please tell us why (Check all that apply)

q I am too ill.

q I feel healthy.

q I am too busy.

q I see my own doctor.

q I thought the Program had ended.

q Exam is too long.
Which exam?

q WTC Health Program clinic schedule does not work for me.
What days/times would work?

q I don’t like the location.
Please explain:

q WTC Health Program clinic staff do not speak my language.
What language do you speak?

q I have a concern about the quality of care.
What is your concern?

q Other:

Care from Your WTC Health Program Provider in the Last Two Years

The next set of questions are about your experience visiting your assigned Clinical Center of Excellence (CCE) and/or National Provider Network (NPN) provider within the last two years.

If you have not been to a WTC Health Program Provider in the last two years, please check here q and skip to the section of the survey About You.

1. Using this scale, Tell us how difficult or easy it has been to access the care, tests, or treatment that you have needed. (Circle the answer that best applies)

Please rate your experience with your Clinical Center of Excellence (CCE) and/or National Provider Network (NPN) using the number that best describes your level of satisfaction for the questions below as follows:

2. Please tell us the ease of scheduling your monitoring/treatment visit

3. Please tell us about the convenience of clinic office hours

4. While at the clinic, how was your wait time to see the doctor/care provider?

5. How satisfied were you with the courtesy and respect given to you by the receptionist and clerks?

6. How satisfied were you with the courtesy and respect given to you by the nurses/assistants?

7. How satisfied were you with the courtesy and respect given to you by your doctor or care provider?

8. How satisfied were you with your doctor/care provider listening to your medical concerns?

9. How satisfied were you with your doctor/care provider explaining things in a way you understood?

10. How satisfied were you with the provider coordinating your care?

11. How satisfied were you with the wait time to receive your test results?

12. How satisfied were you with the cleanliness and appearance of your provider’s office?

13. How satisfied were you with the ease of filling your prescriptions?

14. How satisfied were you with your overall experience with your assigned CCE/NPN office ?

About You

1. In general, how would you rate your overall health?

q Excellent

q Very good

q Good

q Fair

q Poor

2. Think about your health before you joined the Program. Would you say that your current health is:

q Much better than before you joined the Program

q A little better than before you joined the Program

q About the same

q A little worse than before you joined the Program

q Much worse than before you joined the Program

q Don’t know

3. What is your age? ___________

What is your gender?

q Male

q Female

WTC Health Program Communications

The next questions are about communication you receive from the WTC Health Program (not your assigned CCE/NPN.

Do you read the WTC Health Program Annual Newsletter?

• Yes, I read it online

• Yes, I read it in paper copy

• No, I do not read it

Do you read the WTC Health Program Member Handbook?

• Yes, I read it online

• Yes, I read it in paper copy

• No, I do not read it

Would you like to receive WTC Health Program general news and updates by email?* Please opt-in by visiting [insert webpage] and filling out the form.

*Emails include general Program news and updates about benefits, services, and information for all members and the general public. It does not include specific information related to your individual care. You will still receive postal mail from the Program as legally required.

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 WTC Health Program clinic, 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:

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