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House Democrats
Washington Office
Congresswoman Maloney
2332 Rayburn HOB
Washington, DC 20515-3214
202.225.7944 phone
202.225.4709 fax

Manhattan Office
Congresswoman Maloney
1651 3rd Avenue Suite 311
New York, NY 10128-3679
212-860-0606 phone
212-860-0704 fax

Queens Office
Congresswoman Maloney
28-11 Astoria Blvd.
Astoria, NY 11102-1933
718-932-1804 phone
718-932-1805 fax
Online 9/11 Health Questionnaire

In the years following the attacks of September 11, 2001, we have received numerous reports of health related concerns among 9/11 responders, area workers, residents and schoolchildren. In an effort to put a public face on this growing problem, I am asking individuals exposed to the toxins of Ground Zero to share their stories with me. Collecting this information will allow us to better understand the individual sacrifice many have made following 9/11. If you are willing to share your story, I ask that you take a few minutes to fill out the questionnaire below.
* Title:
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State
* Zip Code:
* Primary Phone:
Secondary Phone:
* Email:
* Confirm Email:
Affiliation:
Area Worker
Area Student
Resident
Responder (rescue, recovery, restoration, clean up)
Volunteer
Other:

If you are a responder or volunteer:

Please indicate profession:
Construction Worker
EMT
Fire Fighter
National Guard
Police Officer
Other:
Please identify your occupation or organization. Please provide your specific division, unit, and union if applicable.
Briefly describe your work related to 9/11:

If you are an area worker, resident, or a student:

Briefly describe your exposure to Ground Zero:

General Questions:

1. * Do you believe that you are sick or are you experiencing adverse health effects as a direct result of 9/11?
Yes No
2. If yes, briefly describe your illness:
3. * Are you currently in any 9/11 – related monitoring program or registry?
Yes No
4. If yes, which one?
World Trade Center Medical Monitoring Program (coordinated by Mount Sinai)
FDNY Medical Monitoring Program
Federal Employees Medical Screening Program
New York State Employee Medical Screening Program
Bellevue Hospital Resident Medical Monitoring Program
Other:
5. * Have you signed up with the NYC DOHMH World Trade Center Registry?
Yes No
6. * Are you undergoing any medical treatment for injuries, illnesses related or adverse health effects related to 9/11?
Yes No
7. Do you have adequate insurance to cover the costs associated with this treatment?
Yes No
8. If no, please describe shortfalls in your medical coverage.
9. * Have you ever filed a workers compensation claim related to your 9/11 work?
Yes No
10. If yes, where was the claim filed?
New York
New Jersey
Connecticut
Other:
11. If yes, what was the outcome?
12. * Did you file a claim with the 9/11 Victims Compensation Fund?
Yes No
13. If yes, what was the outcome?
14. * Have you experienced any financial hardship as a result of your work related to 9/11?
Yes No
15. If yes, please explain.
16. Please indicate if there is any additional information you would like to share with us:
* Do you give me permission to share the details of your story?
Yes Yes but contact me first No