Form 0920-1348 NFR User Profile

DRAFT

DRAFT

Attachment 3b. User Profile

Form Approved

OMB No. XXXX

Exp. Date xx/xx/20xx

Protocol Appendix E

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 ______________

  

  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

    • In what year did you stop working in the fire service?

  • Academy Student

  • Out on long-term disability

  • Other

    • If other, please specify ___________________________

1