0920-20MT NFR User Profile

Attachment 3b. User Profile

Form Approved

OMB No. XXXX

Exp. Date xx/xx/20xx

CDC estimates the average reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestion for reducing the burden to CDC/ATSDR Information Collection Review Office, 1500 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

User Profile Questions

• What is your full name?

  • First: _______________________

  • Middle: _____________________

  • Last: ______________________________________________

• Have you been known by any other name (example, maiden name)?

  • No

  • Yes

    • [If yes] What name? First ______________ Last ______________

• What is your date of birth? (scrolling menu)

  • Month____ Day ____ Year ____

• Country of Birth ________City of Birth __________State of Birth _______

  

  If a user provides a DOB that makes them younger than 18 years old, the following dialogue will pop up. “According to your date of birth, you are younger than 18 years of age. Unfortunately, you are not eligible to be in the NFR at this time. Please consider registering when you have reached 18 years of age or older.”

• What is your current residential address?

  • Street: ________________________

  • City: __________________________

  • State: (scrolling menu) ____________

  • Zip code: ______________________

• We would like to keep you updated on the progress of the NFR. We have the following email address on file for you (auto-filled from information provided in login.gov). Would you like to provide another email address? A personal email address is preferred for communications because you should have access to this email even outside of work.

  • __________________________________

• If you would also like to receive updates via text message, please provide your mobile number below

  • (xxx)xxx-xxxx

• What is your current work status in the fire service (select all that apply)?

  • Full time, paid

  • Part time, paid

  • Volunteer (full or part time)

  • Seasonal

  • Paid on call or paid per call

  • Retired

    • In what year did you retire? _ _ _ _

  • No longer working in the fire service

  • Out on long-term disability

  • Other

    • If other, please specify ___________________________

• Where is your current, or most recent fire department, agency, or organization located? (scrolling menu of states, Washington D.C., and territories) ______

• What is your current, or most recent fire department, agency, or organization affiliation?

  • (scrolling menu from state selection)_________________________

  • If not listed, please fill-in department name____________________

    • (if department/agency/organization matches fields in database, a pop-up will ask “did you mean __________ department?”

      • [If manually entered] What jurisdiction do/did you serve at this department/agency/organization? (dropdown menu, select all that apply)

        • Federal

        • Military

        • Municipal/City

        • Municipal/County

        • Municipal/District

        • Private

        • Tribal

        • Other

          • [if other, please describe] ________________________

  • Employee ID/Departmental Identification for current or most recent position __________

• Approximately what year did you start working at X department/agency/organization (auto-populated)? [Fill-in 4-digit year] __ __ __ __

• Approximately what year did you stop working at X department/agency/organization (auto-populated)? [Fill-in 4-digit year or select current/present] __ __ __ __

• What job titles do/did you hold at this department/agency/organization? Select all that apply:

  • Structural or Industrial Firefighter

    • As a structural firefighter, which roles most closely apply/applied to you? (select all that apply)

      • Firefighter

      • Firefighter Medic

      • Firefighter EMT

      • Firefighter AEMT

      • Firefighter Paramedic

      • Driver/Engineer/Operator

  • Wildland Firefighter

    • As a wildland firefighter, which roles most closely apply/applied to you? (select all that apply)

      • Engine crew

      • Hand crew

      • Line medic

      • Base camp support staff

      • Smokejumper

  • Company Officer (Lt, Cpt, Sgt)

  • Wildland Supervisor or Overhead

  • Chief

    • Fire Chief

    • Battalion/District Chief

    • Assistant Chief

    • Deputy Chief

    • Division Chief

  • Fire Investigator, where this is your primary job assignment

  • Instructor, where this is your primary job assignment

  • Superintendent/Crew Boss

  • EMT/Paramedic, where this is your primary job assignment

  • Fire Marshall

  • Other

• Please specify Have you ever been diagnosed with cancer?

• No

• Yes

  • [If yes] What type(s) of cancer were you diagnosed with? Please select where the cancer(s) started (primary site):

    • Bladder

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Brain or Central Nervous System

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Breast

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Cervix

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Colon or Rectum

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Esophagus

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Hodgkin's Lymphoma

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Kidney

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Leukemia

      • [if selected] What type of leukemia were you diagnosed with?

        • Acute myeloid (or myelogenous) leukemia (AML)

        • Chronic myeloid (or myelogenous) leukemia (CML)

        • Acute lymphocytic (or lymphoblastic) leukemia (ALL)

        • Chronic lymphocytic leukemia (CLL)

        • Other or Unsure

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Liver

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Lung

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Mesothelioma

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Multiple Myeloma

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Non-Hodgkin's Lymphoma

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Ovary

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Pancreas

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Prostate

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Skin: Melanoma

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Small Intestine

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Stomach

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Testis

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Thyroid

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Uterus/Endometrium

      • [if selected] What was your age when first diagnosed? _ _ (fill-in)

      • In what state were you living when first diagnosed? (dropdown menu of US states, Washington D.C., territories, and other- please specify)

    • Unsure

    • Other

      • Please specify: _____

• In the United States, each state has a cancer registry that collects and combines information on all cancer diagnoses from all hospitals in that state. Providing your social security number (SSN) is the only way to guarantee the information you provide in your user profile and questionnaire matches any past or potentially future cancer diagnosis reported to a state. This information is necessary to meet the statutory requirements of the Firefighter Cancer Registry Act of 2018. You can choose to provide this information or not. However, without this information, your data may not be included in the analysis of firefighters’ cancer risk. As noted on the informed consent, all your private information will be encrypted, secured, and protected to the fullest extent allowed by law.

  • SSN: __ __ __- __ __-__ __ __ __ (link: why are we asking this?)

  • Confirm SSN: __ __ __- __ __-__ __ __ __

[If participant leaves SSN blank] [Pop-Up box occurs after clicking “next”] We noticed that you did not include an SSN. Would you consider providing your SSN or at least the last four digits? Although not as reliable as your full SSN, the last four digits of your SSN would increase the likelihood of linking your information to any future cancer diagnosis.

• Yes, I’ll provide my SSN

• Yes, I’ll provide my last four digits here

  • [If yes X X X - X X - __ __ __ __]

  • [Confirm SSN: X X X - X X - __ __ __ __]

• No, I do not wish to ensure my identity is correct. I understand this may exclude my information from analyses conducted to estimate cancer risks in firefighters.

[Pop-up box if user clicks “why are we asking this”]

Why are we asking for this?

We need to track firefighters’ health over time to truly understand their cancer risks and improve their protections. Your social security number will let us do this by linking your information to state cancer registries. With this information we can see any potential future cancer diagnosis without any further action from you. Each firefighter that shares this information will increase the accuracy of our findings, which could potentially lead to greater protections for all firefighters. Sharing your social security number will ensure your participation has the maximum impact.

We will protect your information to the fullest extent allowed by law. The National Firefighter Registry is covered by an Assurance of Confidentiality, which is the highest level of protection available for identifiable information. Under this formal protection, we are not allowed to share your identifiable information without your written permission. This means we will not share your social security number, contact information, or identifiable questionnaire responses with outside groups like your employer, insurance company, or even for a lawsuit. Your privacy is as important to us as your participation.