WTC exposure survey form for four distinct populations, October 2006

NYC 9/11 Public Portal Document

i Io t Confidential For Internal Agency use Only

WTC Mayoral Review Panel September 26, 2006

Information Survey

The following survey requests information, to the extent that it is available, on four distinct populations exposed to the WTC site and surrounding area after the 9/11 attacks, to identify who may be at risk to develop a WTC-related illness or are currently ill:

1. City employees;

2. Employees of contractors who worked at the WTC site;

3, Volunteers who worked at the WTC site Red Cross, Salvation Army); and

4. Clients and other constituencies exposed to the WTC site who are ill or may be at risk to develop WTC-related illness fe.g., businesses south of Canal Street, Chinatown residents, etc.)

For the purpose of this survey, “WTC site” means the World Trade Center site, the WTC-related Fresh Kills Landfill operation, the Office of the Chief Medical Examiner (OCME) and any other site where City employees, contractors, volunteers and other City clients or constituencies were exposed to conditions that caused or potentially could cause WTC-related illness.

We ask that you respond to the following requests only for City employees, contractors and volunteers of your agency or for clients and other constituencies served by your agency. This survey .does not seek a definitive or complete account of your agency’s actions with respect to WTC health issues, but rather, is designed for the exclusive purpose of evaluating the current and future availability and sufficiency of resources for persons exposed to the WTC site and who have developed or may be at risk of developing WTC-related illness. Please prepare your responses with that goal in mind. Responses to this survey will be used to develop recommendations for the Mayor.

If you have relevant information that can partially satisfy a request, or information that is relevant but is not specifically requested, please explain what the information is and review the issue with Cas Holloway ((212) 788-8235), or simply provide it. Information can be provided in the format that is easiest for your agency to use (e.g.. Excel spreadsheets); you do not need to fill out this forrn, though it will be helpful if your response is keyed to this request.

Please ensure that any information provided in response to this survey is disclosed in a- manner consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and any rules and regulations promulgated pursuant to the Act.* If you have any

' A summary of HIPAA and relevant rules and regulations prepared by the U.S. Department of Health & Human Services is available at http://v>'ww.hhs.gov/ocr/Drivacvsummarv.Ddf.

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