0920-0891 WTCHP Youth Research Cohort Registration Portal_10FEB202

WORLD TRADE CENTER HEALTH PROGRAM
WTC Youth Research Cohort Questionnaire

Form Approved
OMB No. 0920-XXXX
Exp. Date XX/XX/20XX

This questionnaire is for participation in the World Trade Center (WTC) Youth Cohort. The WTC Youth Cohort includes
persons who were age 21 years or less on September 11, 2011 (9/11), and: were present in the New York City Disaster
Area (NYCDA) on or after 9/11 because of their work, residence, or attendance at school, childcare, or adult daycare or
were present in the NYCDA in the dust or dust cloud on 9/11; OR located outside the NYCDA and in Manhattan not
further north than 14th Street or anywhere within the borough of Brooklyn on 9/11.
If you have questions, call the WTC Health Program at 1-888-982-4748 or visit www.cdc.gov/wtc. To apply online, visit
https://wtchp.cdc.gov/. Note: Participation in in the Youth Research Cohort does not enroll you in the WTC Health
Program or other 9/11 assistance programs such as the September 11th Victim Compensation Fund.
Instructions: Please provide the following information to begin the eligibility determination process. Type or print clearly.
When marking a checkbox, use “” or “”. Incomplete or inadequate information could result in a delay processing your
application.

Personal Information
Were you born between September 12, 1979 and April 25, 2003?:  Yes

 No

If NO, then STOP, you are not eligible for participation in the WTC Youth Cohort. If YES, then please PROCEED:
Were you exposed to 9/11 for at least 1 day beginning September 11, 2001, and ending July 31, 2002, while present
(prenatally or postnatally) in Manhattan, not further north than 14th Street, or in Brooklyn?
 Yes
 No
If NO, then STOP, you are not eligible for participation in the WTC Youth Cohort. If YES, then please PROCEED:
Date of Birth (mm/dd/yyyy)
Sex

 Male

 Female

What is your race and/or ethnicity?
Select all that apply and enter additional details in the spaces below.
 American Indian or Alaska Native
Enter, for example, Navajo Nation Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow
Inupiat Traditional Government, Name Eskimo Community, Aztec, Maya, etc.

_________________________________________________________________________________
 Asian – Provide details below.
 Chinese

 Asian Indian

 Filipino

 Vietnamese

 Korean

 Japanese

Enter, for example, Pakistani, Hmong, Afghan, etc.

_________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 30 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 H21-8, Atlanta, Georgia 30333 ATTN: PRA 0920-0891

 Black or African American – Provide details below.
 African American

 Jamaica

 Haitian

 Nigerian

 Ethiopian

 Somali

Enter, for example, Trinidadian and Tobagonian, Ghanaian, Congolese, etc.

_________________________________________________________________________________
 Hispanic or Latino – Provide details below.
 Mexican

 Puerto Rican

 Salvadoran

 Cuban

 Dominican

 Guatemalan

Enter, for example, Colombian, Honduran, Spaniard, etc.

_________________________________________________________________________________
 Middle Eastern or North African– Provide details below.
 Lebanese

 Iranian

 Egyptian

 Syrian

 Iraqi

 Israeli

Enter, for example, Moroccan, Yemeni, Kurdish, etc.

_________________________________________________________________________________
 Native Hawaiian or Pacific Islander– Provide details below.
 Native Hawaiian

 Samoan

 Chamorro

 Tongan

 Fijian

 Marshallese

Enter, for example, Chuukese, Palauan, Tahitian, etc.

_________________________________________________________________________________
 White– Provide details below.
 English

 German

 Irish

 Italian

 Polish

 Scottish

Enter for example, French, Swedish, Norwegian, etc.

_________________________________________________________________________________

Prenatal Exposure
Prenatal exposure is that amount of qualifying exposure accrued by the cohort registrant in utero via the enrollee’s
mother, who was the direct recipient of the otherwise qualifying exposure. Please answer the following questions about
your location and exposure on September 11. 2001 only if you were in utero at the time. This information is used to
determine research eligibility grouping. The New York City Disaster Area (NYCDA), which is defined as the area of

Manhattan that is south of Houston Street. It also includes any block in Brooklyn that is wholly or partially contained within
a 1.5-mile radius of the former World Trade Center site. To see a map of this area, go to www.cdc.gov/wtc/define.html.
Please select all boxes that apply.
1.

While pregnant with you, was your mother you present on September 11, 2001 and located within the NYCDA
at any time after the first plane impact (i.e., 8:46 AM)?
 Yes  No  Don’t Know/Not Sure

2.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother reside:
 Inside the NYCDA
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA in Manhattan but not further north of 14th street
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA, but elsewhere in Brooklyn
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

3.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother work:
 Inside the NYCDA
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA in Manhattan but not further north of 14th street
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA, but elsewhere in Brooklyn
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

4.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother
participate in voluntary or paid work involving 9/11 rescue, recovery, or clean-up activities?
Yes  No  Don’t Know/Not Sure
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

Postnatal Exposure
Postnatal exposure is the amount of qualifying exposure accrued by the cohort enrollee after birth.

Please answer the following questions about your location and exposure on September 11. 2001. This information is used
to determine exposure levels if you were born before 9/11. The New York City Disaster Area (NYCDA), is defined as the
area of Manhattan that is south of Houston Street. It also includes any block in Brooklyn that is wholly or partially
contained within a 1.5-mile radius of the former World Trade Center site. To see a map of this area, go to
www.cdc.gov/wtc/define.html. Enrolling in the WTC Youth Cohort DOES NOT enroll you in the WTC Program.
Please select all boxes that apply.
1.

While pregnant with you, was your mother you present on September 11, 2001 and located within the NYCDA
at any time after the first plane impact (i.e., 8:46 AM)?

 Yes  No  Don’t Know/Not Sure
2.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother reside:
 Inside the NYCDA
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA in Manhattan but not further north of 14th street
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA, but elsewhere in Brooklyn
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

3.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother work:
 Inside the NYCDA
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA in Manhattan but not further north of 14th street
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________
 Outside the NYCDA, but elsewhere in Brooklyn
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

4.

While pregnant with you at any time between September 11, 2001, and July 31, 2002, did your mother
participate in voluntary or paid work involving 9/11 rescue, recovery, or clean-up activities?
Yes  No  Don’t Know/Not Sure
If yes, then state to the best of your knowledge, from (mm/yyyy) to (mm/yyyy)
____________________________

Contact Information
First Name ____________________________

Middle Name ____________________________

Last Name_____________________________
Country____________________________
Address Line 1 ____________________________
Address Line 2 ____________________________
City____________________________

State ______

Email Address ____________________________
Phone ________________________________
 Cell
 Home

Zip Code____________

 Work
Contact Preferences

 US Mail

 Phone

 Email

 I give the WTC Health Program permission to contacted about future research if eligible unless I opt-out of the WTC
Youth Cohort after submission.

Voluntary Information
How did you hear about the Youth Research Cohort?
 TV/Radio/Print Ad

 Social Media  Work

 WTC Health Registry  Law Firm

 Online

 Labor Union

 Friend

 VCF

 Outreach Partner – if selected, please choose outreach partner:
 9/11 Environmental Action
 FealGood Foundation
 Hispanic Federation
 NYCOSH
 Other Outreach Partner
 Other – if selected, please specify:
_________________________________________________________________________________