BP OIl Spill Disaster Health Survey


Fields marked with * are required.
 
 
 
 

Including your contact information is valuable but not required. The information you have provided will be used to better understand the effects of an oil spill on human health. It may also be used to demonstrate the need for more providers and healthcare facilities that offer treatment for illnesses resulting from chemical exposures.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Smoking History

 
 
Do you smoke? 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

A new Medicare modifier ‘CS’ for “chemical spill” was created for medical insurance claims directly related to the BP Oil Spill. It was activated on January 2, 2011 to monitor the potential short and long-term health and cost impacts of the oil spill. If you are a Medicare patient, ask your provider and insurance about retroactively including this code to cover medical visits for symptoms related to the oil spill.

 
 
 
 
Potential Exposure to BP Crude and/or Dispersants
 
 
 
 
Were you exposed to environmental contamination through 
 
 
 
 
 
 
 
 
 
Human Health Impacts Associated with Louisiana Sweet Crude Oil and Dispersants used in the BP Disaster 
 
Please check off health symptoms you have experienced since the BP Disaster 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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BP Spill Health Survey

Online Health Survey

If you do not have time now, you can download a copy of the survey and mail bacck to our office.
Select file type (PDF or Word)

doc Oil_Spill_Health_Survey.doc

pdf Oil_Spill_Health_Survey.pdf

Extra BP SPill Health Resources

Science Corps’s Crude Oil & Dispersant Health Hazards: http://www.sciencecorps.org/crudeoilhazards.htm

Doctors who will test for oil & dispersant toxins: http://www.examiner.com/environmental-news-in-new-orleans/where-to-find-a-doctor-who-will-test-for-with-oil-and-dispersant-toxins

Reach NOLA's Health resource guides: http://reachnola.org/resources.php

Links to information on chemical info & health risks of Corexit 9500: http://www.toxipedia.org/display/toxipedia/Corexit+9500 & Corexit 9527: http://www.toxipedia.org/display/toxipedia/Corexit+9527

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