WORLD TRADE CENTER WORKER AND VOLUNTEER

MEDICAL SCREENING PROGRAM

EXPOSURE QUESTIONNAIRE-Elevator Constructors Local 1

The World Trade Center Worker and Volunteer Medical Screening Program is a comprehensive medical evaluation program to provide FREE and CONFIDENTIAL medical examinations, referrals for medical care, and occupational health education for 8,500 workers and volunteers who provided Rescue, Recovery, Debris Removal and Sifting and Restoration of Vital Support Services at the WTC and Staten Island landfill sites.

The Program is directed by The Mount Sinai Center for Occupational and Environmental Medicine, in partnership with the National Institute for Occupational Safety and Health of the Centers for Disease Control and Prevention, with medical examinations and related services performed by a consortium of occupational medicine providers.

Limited funding does not allow all exposed workers to be examined. Currently there is an effort in Congress to obtain additional funding to increase the number of people who can receive medical screening examination.

Please complete the following questions:

Today’s Date: __ __/__ __/__ __ __ __ Union/Local Number:___________/______________

Last Name: __________________________________ First Name: _________________________________

Home Address: ____________________________________________________________________________

City: ________________________________________ State: ___________ Zip Code: _______________

PHONE #: (___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___ Circle One: Day Evening Both

work

(___ ___ ___) - ___ ___ ___ - ___ ___ ___ ___ Circle One: Day Evening Both

home

Experience at the World Trade Center and the Staten Island landfill

Y / N Did you work or volunteer in the area bounded by Chambers Street on the north,

Broadway on the east, Rector Street on the south and the Hudson River on the West?

Y / N Did you work or volunteer at the Staten Island Landfill?

Y / N Did you work at the barge loading piers?

Y / N Did you work for the Office of the Chief Medical Examiner?

Y / N Did you work or volunteer in any areas not mentioned above but south of Canal Street?

During the month of September 2001, how many hours per day did you work or volunteer? Ask caller: How many hours did you work or volunteer September 11… How many hours did you work or volunteer September 12…Continue for all days in September. Record number of hours on the calendar below:

Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
		Sep. 11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30

2. How many hours per week did you work or volunteer during:

- the week ending October 6^th? (first week in October) ________________________

- the week ending October 13^th? (second week in October) ________________________

- the week ending October 20^th? (third week in October) _______________________

- the week ending October 27^th? (last week in October) _________________________

- the week ending November 3? _____________________________

- the week ending November 10^th? (first full week in November) _____________________

- the week ending November 17^th? _____________________

- the week ending November 24^th ? _____________________

- the week ending November 30^th? ______________________

- the week ending December 7^th? (first full week in December) _____________________

- the week ending December 14^th? _____________________

- the week ending December 21^st? _____________________

- the week ending December 28^th? ______________________

How many days did you work or volunteer for at least 8 hours per day in:

January 2002_____ February______ March_____ April_____ May_____

During the month of September, how many hours did you work or volunteer (as applicable)

• in the area bounded by Chambers Street on the north, Broadway on the east, Rector Street on the south and the Hudson River on the West?
• at the Staten Island Landfill?
• at the barge loading piers?
• for the Office of the Chief Medical Examiner?

____________ hours

During the period of 9/11-9/14 inclusive, how many hours did you work or volunteer (at the same place/function)

____________ hours

Federal funding for this program will support 7,500 medical screening examinations to begin July 15 in the

Greater NY-NJ metropolitan area—with 1,000 additional screening examinations offered elsewhere in the

US through the Association of Occupational & Environmental Clinics.

New York/New Jersey participating partners and examination locations will include:

Manhattan: Mount Sinai Center for Occupational & Environmental Medicine

Bellevue/NYU Occupational & Environmental Medicine Clinic

Queens: Queens College Center for the Biology of Natural Systems

Long Island: SUNY Stony Brook/L.I. Occupational & Environ. Health Center with various examination sites

in Nassau and Suffolk Counties

Westchester (Yonkers): Mount Sinai Center for Occupational & Environmental Medicine / Hudson Valley

Division at St. John’s Riverside Hospital

New Jersey (Piscataway): UMDNJ Environmental & Occupational Health Sciences Institute

The WTC Building Trades Support Network is a joint program of the BCTC of Greater New York and Cornell University, dedicated to assisting construction workers cope with the effects of their World Trade Center experience.

Please check here ž if you are interested in participating in the WTC Building Trades Support Network.