Citizen’s Toxic Mapping Project & DAtabase: SSFL

Your information will be used to create an online map to better understand the patterns of health issues in the communities surrounding the Santa Susana Field Lab, and will be kept confidential.

YOUR IDENTIFYING INFORMATION WILL NOT BE PUBLIC AT ANY TIME.

This is a preliminary questionnaire to determine if there are abnormal rates of disease, or patterns of disease, for people living within 15 miles of the Santa Susana Field Lab. This information will be useful in determining if a disease cluster exists. We may contact you at a later time to verify your information or about optional next steps (such as working with epidemiologists, class-action lawyers, etc.).

We will use an ID number and a randomized version of the address where you live(d) when diagnosed so that you, your family, or your home can't be directly identified. Your map marker will include an ID number, the type of diagnosis and year of diagnosis and sex. Your personal information (such as your name, contact info, real address, etc.) won't ever be public and will be stored in a secured database. This project is not required to be HIPPA compliant, however, we promise we will never share your information without your implicit, prior permission. We value your privacy and strive to be a completely trustworthy organization.

OPTIONAL: You can verify your diagnosis with medical paperwork that includes your medical provider, your name, and diagnosis. This will help us improve the accuracy and trustworthiness of our study. After verifying your information your verification will be immediately deleted to protect your privacy. Please hide any sensitive information before sending, such as your medical record number or social security number. You can contact us with questions or email us your image or document at santasusanacampaign (@) gmail.com.

By answering this questionnaire you agree to participate in this voluntary opportunity and that you will not hold Parents Against Santa Susana Field Lab liable for any real or perceived damages relating to this project.

Click on the health issue you wish to report, you may enter more than one if needed. The map and database are still under construction. Please contact us if you’d like a health diagnosis to be added.

Allergies and asthma

Autoimmune diseases

Cancer or tumors

Developmental/neurological issues

Urinary System

Gastrointestinal Disorders

  • Achalasia

  • Celiac Disease (see Autoimmune section)

  • Crohn’s disease

Congenital anomalies

  • Abnormal limbs

  • Cleft lip or cleft palate

  • Heart defects

  • Spina bifida

  • Other

Pregnancy complications

reproductive issues (men and women)

unwell/unknown/undiagnosed

  • Abdominal pain, unexplainable (more than 6 months)

  • Digestion issues, unexplainable (for more than 6 months)

  • Other