J-25 Monitoring Qtr Rpt.pdf
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- 2010-N-12135
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World Trade Center - Monitoring Program Participants Version LM-13 Quarterly Report for: 10/01/2009 to 12/31/2009 25-Jan-2010
Clinical Center:
Enter data in colored boxes Enrollees (responders registered with the clinic as of end date of report)
Service Dates 01/01/2009 to
03/31/2009 04/01/2009 to
06/30/2009 07/01/2009 to 09/30/2009
10/01/2009 to 12/31/2009
Past 4 Quarters
Since Inception
Exams Visit 1 (Baseline) 0 Visit 2 (First Follow-Up) 0 Visit 3 (Second Follow-Up) 0 Visit 4 (Third Follow-Up) 0 Visit 5 (Fourth Follow-Up) 0 Visit 6 (Fifth Follow-Up) 0 Visit 7 (Sixth Follow-Up) 0
TOTAL 0 0 0 0 0 0
Referrals to Treatment Program 0
Conditions (diagnosed/ suspected) Upper Airway 0 Lower Airway 0 Gastrointestinal 0 Musculoskeletal 0 Mental Health 0 Total Unique Persons (same as number of referrals) 0
Comorbidities (unique patients in each row) Cardiac 0 Musculoskeletal 0 Endocrine/Renal/GI 0 Cancer 0 Other 0 Patients with any comorbidity 0
Employment Status @ time of visit Currently Employed 0 Unemployed/Laid off 0 Extended Sick Leave/Disability 0 Retired 0 Other 0 No Answer Provided 0No Answer Provided 0
TOTAL 0 0 0 0 0
Occupation @ time of visit Construction 0 Law Enforcement 0 Civilian Public Sector 0 Technical and Utilities 0 Transportation 0 Cleaning/Maintenance 0 Volunteer 0 Firefighter (not FDNY) 0 Healthcare 0 News Agency 0 Office/Administrative/Professional 0 Federal Employee 0 Other Occupation 0 Not Currently Employed 0 No Answer Provided 0
TOTAL 0 0 0 0 0
Mx Qtr Rpt Example 20100518.xlsx Page 1 of 3
Service Dates 01/01/2009 to
03/31/2009 04/01/2009 to
06/30/2009 07/01/2009 to 09/30/2009
10/01/2009 to 12/31/2009
Past 4 Quarters
Since Inception
Insurance Status @ time of visit Yes 0 No No Answer Provided 0
TOTAL 0 0 0 0 0
Insurance Category @ time of visit Aetna 0 Blue Cross/Blue Shield 0
GHI 0
HIP 0
Other Managed Care/PPO 0 Other Managed Care/HMO 0 Other 0 Medicaid 0 Medicare 0 No Answer Provided 0
TOTAL 0 0 0 0 0
Workers' Compensation WC Claim filed for WTC-related condition 0 Medical care for WTC-related conditions through WC claim 0
Line of Duty LODI Claim filed for WTC-related condition 0 Medical care for WTC-relted condition through LODI claim 0
Notes:
Rows 15, 42, 60, and 66 should match.
Rows 17 and 25 should match.
Mx Qtr Rpt Example 20100518.xlsx Page 2 of 3
Instructions and Comments The number of enrollees (cell G5) is how many eligible registrants in the NRHP who are participating or were unable to contact. It does not include those who are ineligible, whose All numbers in column F (Past 4 Quarters) are calculated in the spreadsheet as the sum of In later quarterly reports, the past quarters' numbers may be changed to reflect updates or corrections, but changes should be explained in an accompanying narrative report (with Exams The "Since Inception" numbers are based on historical records from other sources as well as All of the exam numbers are based on having the dates of all exams for every responder who is currently registered in the NRHP, which is the number in row 5.
Referrals to Treatment Program This is the number of responders who completed exams in the period and were referred for follow-up care, even if they have not gone for care within the period.
In a separate report, it will be important to know how many responders who were referred for care fail to go for care within 3 months or some other appropriate timeframe.
Conditions (diagnosed/ suspected) All ICD codes that are identified in the exam as WTC-related should be included in the appropriate category. Thus, the sum of the categories will exceed the number of responders A claims report will be provided which gives the ICD data that are used for this table.
Comorbidities (unique patients in each row) These are health conditions that are not now covered by the WTC Program but are being tracked because of possible future coverage if a relationship with WTC exposures is All ICD codes for health conditions being tracked but not yet covered that are identified in the exam should be included in the appropriate category. Thus, the sum of the categories will A claims report will be provided which gives the ICD data that are used for this table.A claims report will be provided which gives the ICD data that are used for this table.
Employment Status @ time of visit This information is taken from the MHQ at the time of the interview but it will be reported in Occupation @ time of visit This information is taken from the MHQ at the time of the interview but it will be reported in Insurance Status @ time of visit This information is taken from the MHQ at the time of the interview but it will be reported in Insurance Category @ time of visit This information is taken from the MHQ at the time of the interview but it will be reported in The category "Other" is for all other insurances.
Workers' Compensation This information is taken from the MHQ at the time of the interview but it will be reported in Line of Duty This information is taken from the MHQ at the time of the interview but it will be reported in
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