0920-1348 National Firefighter Registry (NFR) Enrollment Questionn
[NIOSH] National Firefighter Registry for Cancer
Attachment 3c. Enrollment Questionnaire_revised_Feb-2025_clean_
NFR Enrollment Questionnaire
OMB: 0920-1348
NFR Enrollment Questionnaire
Form Approved OMB
No. 0920-1348 Exp. Date 04/30/2026
CDC estimates the average
reporting burden for this collection of information as 30 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 (0920-1348).
National Firefighter Registry for Cancer (NFR)
Enrollment Questionnaire
Demographics
First Name ______(auto-populates from user profile)__________________
Middle Name_____(auto-populates from user profile) _________________
Last Name_______(auto-populates from user profile) _________________
Employee ID number (e.g., badge number) for current or most recent position ___________________
What is your race and/or ethnicity? Select all that apply.
American Indian or Alaska Native (for example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)
Asian (for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)
Black or African American (for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
Hispanic or Latino (for example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)
Middle Eastern or North African (for example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
Native Hawaiian or Pacific Islander (for example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)
White (for example, English, German, Irish, Italian, Polish, Scottish, etc.)
What is the highest grade or year of school you completed?
Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
Grades 9 through 11 (Some high school)
Grade 12 or GED (High school graduate)
College for 1 year to 3 years (Some college or technical school)
College for 4 years or more (College graduate or advanced graduate education)
What is your marital status? (Dropdown)
Married
Living with a partner as an unmarried couple
Never married
Divorced
Separated
Widowed
Prefer not to answer
What is your height? (Dropdown) _____ feet ______inches
What is your current weight? (Numerical Fill-in) _______ pounds (if pregnant, please report pre-pregnancy weight)
Work and Exposure
Please answer the following questions on your work history. Please include both volunteer and paid work when answering these questions.
What is the total amount of time you have worked in the fire service?
_____years OR______ months
In what year did you first work as a firefighter? __ __ __ __
How many fire departments or agencies have you worked at? [numerical fill-in] _________
You have worked for X departments starting in the year XXXX. Please provide more details about your time in these departments by filling out the records below. Start with your most recent department and end with the first department you worked for. [X auto-populated with response from question 16]
What is the name of your current or most recent department, agency, or organization?
Department’s state [Auto-populated from the User Profile but can be edited here as a new record; Dropdown of states/territories]
Search: Department, Agency, Organization [Auto-populated from the User Profile but can be edited here as a new record; Dropdown 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 _________ [Auto-populated from the User Profile but can be edited here as a new record; Free text]
[If manually entered as Other] What jurisdiction do/did you serve at this department, agency, or organization? [Auto-populated from the User Profile but can be edited here as a new record; Dropdown menu, select all that apply]
Federal
Military
State
City
County
District
Private
Tribal
Other
[if other, please describe] ________________________
At X department/agency/organization (auto-populated)?
Tell us about the job titles you’ve held at X department/agency/organization (select all that apply).
Structural or Industrial Firefighter (select type)
Firefighter
Firefighter/Medical (e.g., EMT, Paramedic)
Driver/Engineer/Operator
Company Officer (Lt, Cpt, Sgt)
Chief (select type)
Fire Chief/Commissioner
Battalion/District Chief
Assistant Chief
Deputy Chief
Division Chief
Wildland Firefighter (select type)
Engine crew
Hand crew
Line medic
Base camp support staff
Smoke jumper
Aviation Crew
Wildland Supervisor or Overhead
Superintendent/Crew Boss
Fire Marshal
Fire Investigator, where this is your primary job assignment
Instructor, where this is your primary job assignment
EMT/Paramedic, where this is your primary job assignment
Other
Please specify
Of the job titles you selected, please tell us more about them:
Job title X [Auto-populated from question above]
Approximate year started working: [Fill-in 4- digit year] __ __ __ __
Approximate year stopped working: [Fill-in 4-digit year or select currently working in this position] __ __ __ __
What best describes this position?
Full time
Part time
Volunteer
Seasonal
Paid on call or paid per call
Other
[if other, please specify] _________________________________
[*This
question would repeat for each job title selected]
Did you respond to fires or hazmat incidents during your time as X (job title auto-populated with information above)? (Yes/No) (dropdown menu)
No
Yes
(If yes) What types of fire or hazmat incidents did you respond to during your time as X at XX? (auto-populates with job title and department name) (select all that apply)
Structural Fires
Vehicle Fires
Outside Rubbish Fires or Dumpster Fires
Live-Fire Training/Instruction
Fire Investigation (post-extinguishment)
Vegetation/Brush Fires (not including wildland fires)
Wildland Fires or Wildland Prescribed Burns
Wildland Urban Interface Fires
Industrial Fires
Aircraft Crash Rescue
Marine Vessel Fires
Informal Settlement Fires (e.g., communities of people experiencing homelessness)
HAZMAT Response/Spill
Of the incidents you selected, please estimate the average number of responses to each type in a typical year during your time in this position (incident types auto-populated from previous question).
Structural Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Vehicle Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Outside Rubbish Fires or Dumpster Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Live-Fire Training/Instruction
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Fire Investigation (post-extinguishment)
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Vegetation/Brush Fires (not including wildland fires)
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Wildland Fires or Wildland Prescribed Burns
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
(Always display, no conditions) On average, approximately how many days do you/did you spend actively responding to wildland fires in a year? ________
Wildland Urban Interface Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Industrial Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Aircraft Crash Rescue [dropdown menu]
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Marine Vessel Fires
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
Informal Settlement Fires (e.g., communities of people experiencing homelessness)
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
HAZMAT Response/Spill
[fill in with numerical values only] __________ Average number per year
I’ve responded to this, but less than once per year
[*The three questions above would repeat for each job title selected]
[*If more than one department was noted in Question 17, the questionnaire would return to Question 18, but with slightly different wording (below)]
What is the name of your 2nd most recent department, agency, or organization?
[*This would repeat “3rd most recent, etc.” for the total number of departments listed in Question 17]
Throughout your entire career, have you ever used Aqueous Film-Forming Foam (AFFF)?
No
Yes
Approximately how many times have you used AFFF (please include all uses such as training, fire suppression, maintenance, etc.)? (numerical fill in) _________
Throughout your career, have you responded to any major events that you would consider unusual in duration or intensity? These events could include: natural disasters, acts of terrorism, industrial events, extreme wildland disasters, etc.
No
Yes
Unsure
[If yes] Please tell us more about this/these major event(s):
Event 1: How would you classify the first event? [repeats for each event]
Natural disaster
Chemical
Industrial/Factory
Wildland
Vegetation
Structural
Terrorist Event
Other
[If other] Please specify ______________________
How long was your personal response to this event? [repeats for each event] _______days OR [dropdown menu for days] ________ hours [dropdown menu for hours]
Was this a named event? (example, 9/11, Hurricane Katrina) [repeat for each event]
No
Yes
[If yes] What was this event commonly known as? ____________
Event 2: How would you classify the second event? [repeats for each event]
Natural disaster
Chemical
Industrial/Factory
Wildland
Vegetation
Structural
Terrorist event
Other
[If other] Please specify ______________________
How long was your personal response to this event? [repeat for each event]
Was this a named event? (example, 9/11, Hurricane Katrina) [repeat for each event]
No
Yes
[If yes] What was this event commonly known as? _______
Have you ever served in the U.S. Armed Forces or other uniformed services?
Yes
Are you currently serving?
Yes
No
Did you ever serve in a combat or war zone?
Yes
No
No, never served in the U.S. Armed Forces or other uniformed services
Have you ever held another job for 6 months or more while also working in the fire service?
No
Unsure
Yes
For your job that overlapped with your fire service career the longest...
What kind of work do/did you do? (for example, registered nurse, janitor, cashier, auto mechanic) ______________ (fill-in, open text)
What kind of business or industry do/did you work in? (for example, hospital, elementary school, clothing manufacturing, restaurant) _______ (fill-in, open text)
What year did you begin that job? [year – numerical fill-in]
Are you currently employed in that job?
No
What year did you end that job? [year – numerical fill-in]
Yes
Over your lifetime, have you ever held a non-firefighting job (or jobs) for at least 100 days or more where you were routinely exposed to smoke, exhaust, or chemicals?
No
Unsure
Yes
Have you implemented the following practices on a regular basis (most of the time) at any point in your career?
Wear SCBA during interior fire attack of a structural/industrial fire
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA during external fire attack of a structural/industrial fire
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during overhaul of a structural/industrial fire
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during vehicle fires
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA, an air purifying respirator with multi-chemical canister/cartridge, or filtering facepiece respirator (example, N95 mask) during brush or vegetation fires
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear air purifying respirator with multi-chemical canister/cartridge or filtering facepiece respirator during wildland fire suppression
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA, air purifying respirator with multi-chemical canister/cartridge, or filtering facepiece respirator (example, N95 mask) while performing or attending fire investigations
Yes
What year did you start doing this regularly? [fill in year] Include checkbox “I’ve always done this”
No
N/A
Wear SCBA or air purifying respirator with multi-chemical canister or cartridge when responding to wildland-urban interface fires
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wear a protective hood during interior fire response
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Conduct preliminary exposure reduction of my PPE (on-scene gross decon of turnout gear)
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Keep used PPE out of passenger compartment of vehicle
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wash/wipe down equipment (radio, SCBA, tools, etc)
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Wash or clean my hands on-scene before taking in food or drink
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Clean your exposed skin on-scene after a fire response (use skin wipes or other cleansing method)
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Prioritize showering as quickly as possible following fire response (for example, “shower within the hour”)
Yes
What year did you start doing this regularly? [year – numerical fill-in] Include checkbox “I’ve always done this”
No
N/A
Have hood laundered after every or almost every fire response?
Yes
[If selected] What year did you start doing this regularly? (year – numerical fill-in) Include checkbox “I’ve always done this”
No
[if “no” selected] Approximately how frequently do you/did launder your hood?
Every 1-2 weeks
Every 1-2 months
Quarterly (4 times a year)
Twice a year
Annually
Less than once a year
Never
[If selected any option other than never] What year did you start doing this regularly? (year – numerical fill-in) Include checkbox “I’ve always done this”
N/A- I do not wear a hood
Have turnout gear or other fire-response clothing laundered after every or almost every fire response?
Yes
[If selected] What year did you start doing this regularly? (year – numerical fill-in) Include checkbox “I’ve always done this”
How do you/did you launder your PPE?
Take it home
Send out via contracted service
Wash it at the station
Take to a laundromat
Department central location (example, Headquarters, Shop, Quartermaster, etc.)
Other
[If other] Please explain _______________
No
[if “no” selected] Approximately how frequently do you/did you launder your turnout gear or other fire-response clothing?
Every 1-2 weeks
Every 1-2 months
Quarterly
Twice a year
Annually
Less than once a year
Never
[If selected any option other than never] What year did you start doing this regularly? (year – numerical fill-in) Include checkbox “I’ve always done this”
[If selected any option other than never] How do you/did you launder your PPE?
Take it home
Send out via contracted service
Wash it at the station
Take to a laundromat
Department central location (example, Headquarters, Shop, Quartermaster, etc.)
Other
[If other] Please explain _______________
N/A
Please answer the next group of questions based on your current (for current firefighters) or most recent assignment (for former/retired firefighters).
What is/was your typical shift configuration?
24 hours on/24 hours off
24 hours on/48 hours off
24 hours on/72 hours off
48 hours on/96 hours off
24 hours on/24 hours off/24 hours on/24 hours off/24 hours on/4 days off (Kelly shift)
72 hours on/96 hours off
9 hours on/15 hours off
10 hours on/14 hours off
10 hours, 4 days per week
12 hours on/12 hours off
8 hours on, 5 days per week, unless deployed
5-6 (5-24 hour shifts, 6 days off)
On-call
Volunteer, on-call continuously
Seasonally deployed
Other
[If other] Please specify ________________
On average, how many calls do you/did you run in a shift?
[dropdown with numerical options starting with 0-20] _____________
I don’t operate on shift
On average, how many hours of uninterrupted sleep do you/did you get in a 24-hour period when on duty or on call?
[dropdown with numerical options ranging from 0-24] _____________
On average, how many hours of uninterrupted sleep do you/did you get in a 24-hour period when you are not/were not on duty or on call?
[dropdown with numerical options raning from 0-24] _____________
Health History
How often do you get an NFPA 1582 compliant or other comprehensive occupational physical exam?
Annually
Once every 2-3 years
I do not routinely have an occupational physical exam
Prefer not to answer
How often do you see a health care provider for a routine check-up?
Annually
Once every 2-3 years
I do not see a health care provider routinely
Prefer not to answer
[ask to participants age 40+] There are different kinds of tests to check for colon or rectal cancer, including colonoscopy, sigmoidoscopy, and stool-based tests. Have you ever had a test to check for colon or rectal cancer?
Yes
[If yes] Approximately how old were you when you had your first test to check for colon or rectal cancer? (numerical fill-in)
[If yes] About how long has it been since your most recent test to check for colon or rectal cancer?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to males age 40+] A PSA is a blood test to detect prostate cancer. It is also called a prostate-specific antigen test. Have you ever had a PSA test?
Yes
[If yes] Approximately how old were you when you had your first PSA test? (numerical fill-in)
[If yes] How long has it been since your most recent PSA test?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to females age 25+] There are two different kinds of tests to check for cervical cancer. One is a Pap smear or Pap test and the other is the HPV or Human Papillomavirus test. Have you ever had a test to check for cervical cancer?
Yes
[If yes] Approximately how old were you when you had your first test to check for cervical cancer? (numerical fill-in)
[If yes] When did you have your most recent test to check for cervical cancer?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
[ask to females age 30+] A mammogram is an x-ray taken only of the breast by a machine that presses against the breast. Have you ever had a mammogram?
Yes
[If yes] Approximately how old were you when you had your first mammogram? (numerical fill-in)
[If yes] How long has it been since your most recent mammogram?
Within the past year (anytime less than 12 months ago)
Within the past 2 years (1 year but less than 2 years ago)
Within the past 3 years (2 years but less than 3 years ago)
Within the past 5 years (3 years but less than 5 years ago)
Within the past 10 years (5 years but less than 10 year ago)
10 years ago or more
Unsure
Prefer not to answer
No
Unsure
Prefer not to answer
Have you ever been diagnosed with cancer?
No
Unsure if I have ever been diagnosed with cancer
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)
Larynx (e.g., voice box, vocal cords)
[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 (Select all that apply)?
Acute myeloid (or myelogenous) leukemia (AML)
[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)
Chronic myeloid (or myelogenous) leukemia (CML)
[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)
Acute lymphocytic (or lymphoblastic) leukemia (ALL)
[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)
Chronic lymphocytic leukemia (CLL)
[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)
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 which cancer (primary site)
[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)
Other type of cancer
Please specify: ______
[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)
Have you ever been told by a healthcare professional that you have the following conditions?
Diabetes
No
Yes
If yes, what type?
Type 1
Type 2
Gestational
Unsure
High Blood Pressure
No
Yes
High Cholesterol
No
Yes
Overweight
No
Yes
Obesity
No
Yes
Rheumatoid Arthritis
No
Yes
Asthma
No
Yes
Emphysema
No
Yes
Chronic Bronchitis
No
Yes
Heart Disease (e.g. heart attack, heart failure, atherosclerosis)
No
Yes
Stroke
No
Yes
Sleep Apnea
No
Yes
Insomnia
No
Yes
Celiac Disease
No
Yes
Inflammatory bowel disease
No
Yes
If yes, what type?
Crohn’s Disease
Ulcerative Colitis
Unsure
Other
Please specify
Colorectal Polyps
No
Yes
Chronic Hepatitis (Hepatitis B, Hepatitis C)
No
Yes
Post-Traumatic Stress Disorder
No
Yes
Depression
No
Yes
Anxiety
No
Yes
Dementia
No
Yes
Traumatic Brain Injury (concussion)
No
Yes
Coronavirus Disease 2019 (COVID-19)
No
Yes
Have you ever experienced an injury resulting in 3 or more days away from work?
No
Yes
Have you ever experienced a smoke inhalation injury resulting in the need for medical care (such as emergency department visit or health professional consultation)?
No
Yes
Do any of your biological children have a history of cancer?
I do not have any biological children
Unsure if my biological children have a history of cancer
No
Yes
[If yes] For these biological children, where did the cancer(s) start (primary site)?
Bladder
Brain or Central Nervous System
Breast
Cervix
Colon or Rectum
Esophagus
Hodgkin's Lymphoma
Kidney
Larynx (e.g., voice box, vocal cords)
Leukemia
Liver
Lung
Mesothelioma
Multiple Myeloma
Non-Hodgkin's Lymphoma
Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
Ovary
Pancreas
Prostate
Skin: Melanoma
Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown
Small Intestine
Stomach
Testis
Thyroid
Uterus/Endometrium
Unsure which cancer (primary site)
Other
Please specify: _____
Do you have a family history of cancer among your other immediate biological (blood) relatives, including mother, father, and/or sibling(s)?
Unsure if I have a family history of cancer
No
Yes
[If yes] For these blood relatives, where did the cancer(s) start (primary site)?
Bladder
Brain or Central Nervous System
Breast
Cervix
Colon or Rectum
Esophagus
Hodgkin's Lymphoma
Kidney
Larynx (e.g., voice box, vocal cords)
Leukemia
Liver
Lung
Mesothelioma
Multiple Myeloma
Non-Hodgkin's Lymphoma
Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
Ovary
Pancreas
Prostate
Skin: Melanoma
Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or Unknown
Small Intestine
Stomach
Testis
Thyroid
Uterus/Endometrium
Unsure which cancer (primary site)
Other
Please specify: _____
If answer to sex in the user profile is female (males will not see these questions): Have you ever been pregnant?
No
Yes
If yes, how many times have you been pregnant? (numerical fill-in)
How many of your pregnancies resulted in at least one live birth? (numerical fill-in)
How old were you when your first pregnancy occurred? (numerical fill in, unsure, prefer not to answer)
Have you ever breastfed?
No
Yes
Approximately how many months did you breastfeed in total for all births combined? ____months (numerical fill-in)
Prefer not to answer
Unsure
Prefer not to answer
How old were you when you had your first menstrual period? (numerical fill-in) ______________
Have never had a menstrual period
Unsure
Prefer not to answer
Has it been 12 months or more since you had your last menstrual period?
No
Yes
How old were you when you had your last period? (numerical fill-in and unsure)
Why did your menstrual periods stop?
Currently pregnant or nursing
Menstrual periods stopped naturally
Surgery (e.g., hysterectomy or oophorectomy)
Chemotherapy treatments
Hormonal contraceptives (birth control pill, shot, patch, intrauterine device, etc.)
Unsure
Other
Please specify ______________
Have you used any female hormones for two months or more to treat hot flashes or other menopausal symptoms (such as Premarin or other estrogens)?
No
Yes
How old were you when you began using these medications? (numerical fill-in and unsure)
Altogether, for how many months or years in total have you used these medications? (numerical fill-in and unsure) ____months OR ______years
How old were you when you stopped using these medications? (numerical fill-in)
Currently using
Unsure
N/A
Unsure
Prefer not to answer
Have you ever used hormonal contraceptives for two months or more for any reason (birth control, acne, menstrual irregularity, endometriosis, polycystic ovarian syndrome, etc.)?
No
Yes
How old were you when you began using hormonal contraceptives? (numerical fill-in and unsure)
Altogether, for how many months or years have you used hormonal contraceptives? (numerical fill-in and unsure) ______months OR _______years
How old were you when you stopped using hormonal contraceptives? (numerical fill-in
Currently using
Unsure
Unsure
Prefer not to answer
Lifestyle
We are asking about lifestyle behaviors because cancer or other health conditions may be related to a combination of work events and lifestyle choices.
In a typical week, do you perform physical activity that raises your heartrate (such as swimming, biking, brisk walking, jogging, rowing) for at least 150 minutes (2 hours and 30 minutes) per week not including firefighting response activities?
Yes
No
Prefer not to answer
In a typical week, do you perform weight or strength training at least 2 days a week?
Yes
No
Prefer not to answer
After several months of not being in the sun, if you then went out into the sun without sunscreen or protective clothing for one hour, which of these would happen to your skin?
Get a severe sunburn with blisters
Have a moderate sunburn with peeling
Burn mildly with some or no darkening/tanning
Turn darker without sunburn
Nothing would happen to my skin
Do not go out in the sun
How many blistering sunburns have you had in your lifetime?
0
1-5
6-10
10 or more
Please answer the next group of questions based on your current and past uses with tobacco based products.
In your entire life, have you smoked 100 or more cigarettes (note, five packs is equal to 100 cigarettes)?
Prefer not to answer
No
Yes, I currently smoke cigarettes
On average, about how many cigarettes a day do you smoke? (numerical fill-in)
At what age did you first start smoking regularly? (numerical fill-in)
How many years have you smoked, not counting time periods when you had quit? (numerical fill-in)
Yes, I formerly smoked cigarettes
On average about how many cigarettes a day did you smoke? (numerical fill-in)
At what age did you first start smoking regularly? (numerical fill-in)
How many years did you smoke, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last smoked cigarettes?
Did you ever use smokeless tobacco, such as chewing tobacco, snuff, or dip regularly for a year or longer?
Prefer not to answer
No
Yes, I currently use smokeless tobacco regularly
On average, about how many dips per day do you use? (numerical fill-in)
At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
How many years have you used smokeless tobacco, not counting time periods when you had quit? (numerical fill-in)
Yes, I formerly used smokeless tobacco regularly
On average about how many dips per day did you use? (numerical fill-in)
At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
How many years did you use smokeless tobacco, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last used smokeless tobacco?
Did you ever smoke cigars regularly for a year or longer?
Prefer not to answer
No
Yes, I currently smoke cigars regularly
At what age did you first start smoking cigars regularly? (numerical fill-in)
How many years have you smoked cigars, not counting time periods when you had quit?
Yes, I formerly smoked cigars regularly
At what age did you first start smoking cigars regularly? (numerical fill-in)
How many years did you smoke cigars, not counting time periods when you had quit?
How old were you when you last smoked cigars?
Did you ever smoke pipes regularly for a year or longer?
Prefer not to answer
No
Yes, I currently smoke pipes regularly
At what age did you first start smoking pipes regularly? (numerical fill-in)
How many years have you smoked pipes, not counting time periods when you had quit?
Yes, I formerly smoked pipes regularly
At what age did you first start smoking pipes regularly? (numerical fill-in)
How many years did you smoke pipes, not counting time periods when you had quit?
How old were you when you last smoked pipes?
Did you ever vape or use e-cigarettes regularly for a year or longer?
Prefer not to answer
No
Yes, I currently vape or use e-cigarettes regularly
At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
How many years have you vaped or used e-cigarettes, not counting time periods when you had quit?
Yes, I formerly vaped or used e-cigarettes regularly
At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
How many years did you vape or use e-cigarettes, not counting time periods when you had quit? (numerical fill-in)
How old were you when you last vaped or used e-cigarettes?
In the past 30 days, how many days did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. [dropdown with numerical options ranging from 0-30] _____________
[If 0, skip questions 50-51]
During the past 30 days, on the days when you drank, how many drinks did you consume on average? [fill-in, numerical text] __________
Considering all types of alcoholic beverages, how many times in the past 30 days did you consume 4/5 or more drinks on an occasion? [4 will appear for women, 5 will appear for men or missing sex response] [dropdown with numerical options ranging from 0-30] __________
Has a health professional ever told you to consider reducing your alcohol use?
Yes
No
Unsure
Prefer not to answer
You have reached the end of this survey, and we would like to offer you an opportunity to give us feedback:
Optional information you would like us to know about you.
Is there anything else you would like us to know? [narrative box]
Thank you for your participation in the National Firefighter Registry. Please click Submit to complete your enrollment. If you have questions, please feel free to email us at NFRegistry@cdc.gov.
Submit
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Wilkinson, Andrea (CDC/NIOSH/DFSE/FRB) |
| File Modified | 0000-00-00 |
| File Created | 2025-05-19 |
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