Below you will find four situations that may be similar to your own. After each case description, you will find a WTC-12, the registration form, correctly filled out for that situation. Please look through these case descriptions to assist you with filling out your own form.

Also, when completing your own registration form, be sure to refer to the: SIMPLIFIED INSTRUCTIONS FOR REGISTRATION FORM and the NYCOSH 911 WORKERS COMPENSATION REGISTRATION FORM FACT SHEET

Be aware that the sample forms have no signatures and are not notarized, however, both of those are required when you complete your registration form.

John Smith's Case
John Smith is an employee of the City of New York. He was assigned to do clean-up work in lower Manhattan on September 20, 2001 and that remained his assignment for about three months. His work involved the cleaning of streets, buildings, and other structures in the neighborhood that were coated with dust and ash from the collapse of the World Trade Center. He filed a workers' compensation claim in January of 2005 that was dismissed because of late filing.

If your case sounds like John Smith's, click here to view a sample WTC-12 form:
WTC-12-JohnSmith.pdf

Jane Smith's Case
Jane Smith is an employee of an insurance company located a few blocks from the World Trade Center site. She first returned to work in the area two months after 9/11. When she came back to work, her office and other areas where she worked were coated with dust and ash from the World Trade Center collapse. For the next week, she and her co-workers spent part of their time at work cleaning their offices and the common office areas.

If your case sounds like Jane Smith's, click here to view a sample WTC-12 form:
WTC-12-JaneSmith.pdf

John Doe's Case
John Doe is a construction worker who went to Ground Zero on September 11th, 2001. He volunteered for 5 days, doing rescue and recovery work at the site. Although his volunteer work was not coordinated by any specific relief agency, he was interviewed by a newspaper reporter while volunteering, and he has a copy of the article. He also has a photograph of himself on the site at some time during the first five days.

John Doe then returned to the site on January 23, 2002 in the course of his employment with ABC Construction Company, which had a contract for some of the demolition, excavation and construction at the World Trade Center location.

Because he was present at the site as both a volunteer and a worker, John Doeís form covers all of his participation at the site.

If your case sounds like John Doe's, click here to view a sample WTC-12 form:
WTC-12-JohnDoe.pdf

Jane Doe's Case
Jane Doe is a retired private citizen who lives in Brooklyn. She went to the World Trade Center site on September 12, 2001, was accepted as a volunteer by the Red Cross, and volunteered for a week. During that time, she set up tables, handed out water, and generally assisted the rescue and recovery workers. She kept her I.D. badge from the Red Cross, has a letter thanking her for her volunteer service, and also has a photo of herself and other volunteers at the site.

If your case sounds like Jane Doe's, click here to view a sample WTC-12 form:
WTC-12-JaneDoe.pdf