NFR User Profile (web-portal registration)

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NFR 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 ______________
    • Country of Birth __________ State/Territory of Birth _______ City of Birth ______________
    • Month of Birth (Dropdown) ____ ____ Day of Birth (Dropdown) ____ ____ Year of Birth (Numerical fill-in) __ __ __ __  
    • What is your sex? 
        ◦ Male
        ◦ Female


    • 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 the last four digits of your social security number (SSN) will increase the likelihood of linking your profile and questionnaire information to 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. As noted on the informed consent, all your private information will be encrypted, secured, and protected to the fullest extent allowed by law.
        ◦ SSN: XXX-XX-__ __ __ __ (link: why are we asking this?) 
        ◦ Confirm SSN: XXX-XX-__ __ __ __















    • 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 ___________________________
    • What is the name of your current or most recent department, agency, or organization? If you currently serve in more than one department, please list what you consider to be your primary department. You will be able to enter other departments in the enrollment questionnaire.
        ◦ Department’s state [dropdown of states/territories]
        ◦ Search: Department, Agency, Organization [Drop down and/or free text that autopopulates from database of departments based on the state that was selected]
        ◦ If you do not see your department listed please fill it in below
            ▪ Other _________
                • [If manually entered as Other] What jurisdiction do/did you serve at this department, agency, or organization? (dropdown menu, select all that apply)
                    ◦ Federal
                    ◦ Military
                    ◦ State
                    ◦ City
                    ◦ County
                    ◦ District
                    ◦ Private
                    ◦ Tribal
                    ◦ Other
                        ▪ [if other, please describe] ________________________