NYC-WTC_000233682

NYC 9/11 Public Portal Document

RESPONSE GUIDELINES

Exposed Individuals: Location where exposure is thought to have occurred □ Residence □ Work □ School □ Restaurant □ Shopping mall □ Social gathering □ Other:

Additional notes on location of exposure:

Collect addresses for specific locations where exposure is thought to have occurred.

Is the pattern of exposure clustered in a specific area? □ Yes □ No

Extent of area □ Single building □ Complex (several buildings) □ City block □ Neighborhood □ Cluster of neighborhoods □ Large section of city □ Other:

Additional notes on extent of area:

Do the exposed individuals represent a disproportionate number of: □ Immune compromised □ Elderly □ Children □ Infants □ Pregnant women □ Women □ Other: □ None, no specific groups dominate the makeup of exposed individuals

EVALUATION OF LINK TO WATER Are the symptoms consistent with typical waterborne diseases, such as gastrointestinal disease, vomiting, or diarrhea? □ Yes □ No

Does the area of exposure coincide with a specific area of the system, such as a pressure zone or area feed by a specific plant? □ Yes □ No

Were there any consumer complaints within the affected area? □ Yes □ No

Were there any unusual water quality data within the affected area? □ Yes □ No

Were there any process upsets or operational changes? □ Yes □ No

Was there any construction/maintenance within the affected area? □ Yes □ No

Were there any security incidents within the affected area? □ Yes □ No

SIGNOFF Name of person completing form: Print name Signature Date/Time:

28 Interim Final - August 2004

CITY_21MC100_004992367

NYC-WTC_000233710