User Profile

DRAFT

Form Approved

OMB No. 0920-1348

Exp. Date XX/XX/20XX

Attachment 3b. User Profile

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] Other First Name ______________ Other Last Name ______________

• What is your current residential address?

  • Street: ________________________

  • Apt/Suite/Other

  • City: __________________________

  • State: (scrolling menu) ____________

  • Zip code: ______________________

• We have the following email address listed above on file. Would you like to provide another email address that will be used to contact you if we cannot reach you at the primary email address?.

  • __________________________________

• If you would also like to receive updates via text message, please opt-in and 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 (approximate date) ? _ _ _ _

  • No longer working in the fire service

    • In what year did you stop working in the fire service (approximate date)?

  • Academy Student

  • Out on long-term disability

  • Other

    • If other, please specify ___________________________

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 suggestions for reducing this burden to - CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-1348).