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Research has shown that the terrorist attacks in New York City (NYC) on September 11, 2001 had an impact on the psychological status of area residents. Since a major goal of many terrorist attacks is to also adversely affect local socioeconomic activities, the long-term impact of exposure to terrorist attacks on productivity and outpatient service utilization among workers in NYC is assessed.The impact of the World Trade Center disaster (WTCD) among 1,167 workers in NYC is examined using a prospective cohort design. The study included measures of WTCD exposures, stressful life events, other traumatic events, post-traumatic stress disorder (PTSD), and depression, assessed at 1 year and 2 years post-disaster.Bivariate analyses suggest that exposure to WTCD events is associated with high productivity loss at baseline, but not consistently at follow-up. Both PTSD and depression are associated with lower quality workdays at baseline and follow-up, but depression is more consistently associated with high work loss and medical service use. In multivariate analyses, WTCD exposure is associated with productivity loss at baseline, but less consistently at follow-up. At baseline, depression and history of traumatic events are associated with lower quality workdays and negative life events with greater workdays lost. Multivariate analyses at follow-up indicated that experiencing negative life events is associated with higher workdays lost and lower quality workdays and that PTSD is associated with lower quality workdays. Similar regression models suggested that increased outpatient service use is associated with depression and lifetime traumatic events at baseline and with negative life events at follow-up.This study suggests that while the WTCD had an impact on worker productivity within the first year after the attack, this did not generally persist, especially after controlling for baseline status. Having PTSD or experiencing stressful life events at follow-up, however, is associated with lower quality workdays, even after controlling for baseline status. Am. J. Ind. Med. 49:670-682, 2006. © 2006 Wiley-Liss, Inc.