Enrollment Questionnaire

Attachment 3c. Questionnaire
* Information collected through the user profile questionnaire will be automatically uploaded to this
questionnaire to reduce the burden on the firefighter.

Form Approved
OMB No. 0920-1348 Exp.

Date XX/XX/20XX

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 (NFR)
Enrollment Questionnaire
Demographics
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9.

10.

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 ___________________
If a user provides a DOB that makes them younger than 18
years old, the following dialogue will pop up. “According to
Country of Birth __________ State/Territory of Birth _______
your date of birth, you are younger than 18 years of age.
City of Birth ______________
Unfortunately, you are not eligible to be in the NFR at this
Month of Birth (Dropdown) ____ ____ Day of Birth
time. Please consider registering when you have reached
18 years of age or older.”
(Dropdown) ____ ____ Year of Birth (Numerical fill-in) __ __
__ __
Sex Assigned at Birth?
o Male
o Female
Ethnicity- Are you Hispanic or Latino?
o Yes, I am Hispanic or Latino
o No, I am not Hispanic or Latino
Race- select one or more
o American Indian or Alaska Native
o Asian
o Black or African American
o Native Hawaiian or Other Pacific Islander
o White
What is the highest grade or year of school you completed?
o Never attended school or only attended kindergarten
o Grades 1 through 8 (Elementary)
o Grades 9 through 11 (Some high school)
o Grade 12 or GED (High school graduate)
o College for 1 year to 3 years (Some college or technical school)
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11.

12.
13.
14.

o College for 4 years or more (College graduate or advanced graduate education)
o Prefer not to answer
What is your marital status? (Dropdown)
o Married
o Living with a partner as an unmarried couple
o Never married
o Divorced
o Separated
o Widowed
o 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)
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.

[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. Sharing the last
four digits of 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 the last four digits
of 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.

o SSN: XXX-XX-__ __ __ __ (link: why are we asking this?)
o Confirm SSN: XXX-XX-__ __ __ __

Work and Exposure
Please answer the following questions on your work history. Please include both volunteer and
paid work when answering these questions.
15. What is the total amount of time you have worked in the fire service?
o _____years OR______ months
16. In what year did you first work as a firefighter? __ __ __ __
17. 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]
18. What is the name of your current or most recent department, agency, or organization?
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o

[Drop down and/or free text that autopopulates from database of departments based on the state that
was selected state]
 [If manually entered] What state is this department located? [Drop down menu of states]
 [If manually entered] 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
o [if other, please describe] ________________________
o At X department/agency/organization (auto-populated)?
 Approximate year started working [Fill-in 4 digit year]__ __ __ __]
 Approximate year stopped working [Fill-in 4 digit year or select currently working at this
department/agency] __ __ __ __
o 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
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

•

Other
• Please specify

Of the job titles you selected, please tell us more about them:
o

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
o [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)
o No
o Yes
(If yes) What types of fire or hazmat incidents did you respond to during your time as X at XX? (autopopulates with job title and department name) (select all that apply)
o Structural Fires
o Vehicle Fires
o Outside Rubbish Fires or Dumpster Fires
o Live-Fire Training/Instruction
o Fire Investigation (post-extinguishment)
o Vegetation/Brush Fires (not including wildland fires)
o Wildland Fires or Wildland Prescribed Burns
o Wildland Urban Interface Fires
o Industrial Fires
o Aircraft Crash Rescue
o Marine Vessel Fires
o Informal Settlement Fires (e.g., communities of people experiencing homelessness)
o

•

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).
o Structural Fires
 [fill in with numerical values only] __________ Average number per year
 I’ve responded to this, but less than once per year
o Vehicle Fires
4

o
o
o
o
o

o
o
o
o
o

o

 [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]

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19. Have you implemented the following practices on a regular basis (most of the time) at any point in your
career?
o Wear SCBA during interior fire attack of a structural/industrial fire
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear SCBA during external fire attack of a structural/industrial fire
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during overhaul
of a structural/industrial fire
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear SCBA or an air purifying respirator with multi-chemical canister/cartridge during vehicle
fires
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear SCBA, an air purifying respirator with multi-chemical canister/cartridge, or filtering
facepiece respirator (example, N95 mask) during brush or vegetation fires
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear air purifying respirator with multi-chemical canister/cartridge or filtering facepiece
respirator during wildland fire suppression
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
o Wear SCBA, air purifying respirator with multi-chemical canister/cartridge, or filtering facepiece
respirator (example, N95 mask) while performing or attending fire investigations
o Yes
o What year did you start doing this regularly? [fill in year] Include checkbox
“I’ve always done this”
o No
o N/A
o Wear SCBA or air purifying respirator with multi-chemical canister or cartridge when responding
to wildland-urban interface fires
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
6

o

o

o

o

o

o

o

o

o No
o N/A
Wear a protective hood during interior fire response
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Conduct preliminary exposure reduction of my PPE (on-scene gross decon of turnout gear)
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Keep used PPE out of passenger compartment of vehicle
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Wash/wipe down equipment (radio, SCBA, tools, etc)
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Wash or clean my hands on-scene before taking in food or drink
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Clean your exposed skin on-scene after a fire response (use skin wipes or other cleansing method)
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Prioritize showering as quickly as possible following fire response (for example, “shower within
the hour”)
o Yes
o What year did you start doing this regularly? [year – numerical fill-in]
Include checkbox “I’ve always done this”
o No
o N/A
Have hood laundered after every or almost every fire response?
o Yes
o [If selected] What year did you start doing this regularly? (year –
numerical fill-in) Include checkbox “I’ve always done this”
o No
o [if “no” selected] Approximately how frequently do you/did launder your
hood?
7

Every 1-2 weeks
Every 1-2 months
Quarterly (4 times a year)
Twice a year
Annually
Less than once a year
Never
o [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”
o N/A- I do not wear a hood
Have turnout gear or other fire-response clothing laundered after every or almost every fire
response?
o Yes
o [If selected] What year did you start doing this regularly? (year –
numerical fill-in) Include checkbox “I’ve always done this”
o 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 _______________
o No
o [if “no” selected] Approximately how frequently do you/did you launder
your turnout gear or other fire-response clothing?
o Every 1-2 weeks
o Every 1-2 months
o Quarterly
o Twice a year
o Annually
o Less than once a year
o Never
o [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”
o [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.)
o
o
o
o
o
o
o

o

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•
•

Other
[If other] Please explain _______________

o N/A
20. Have you ever served in the U.S. Armed Forces or other uniformed services?
o Yes
o Are you currently serving?
o Yes
o No
o Did you ever serve in a combat or war zone?
o Yes
o No
o No, never served in the U.S. Armed Forces or other uniformed services
21. Have you ever held another job for 6 months or more while also working in the fire service?
o No
o Unsure
o Yes
o For your job that overlapped with your fire service career the longest...
o What kind of work do/did you do? (for example, registered nurse, janitor,
cashier, auto mechanic) ______________ (fill-in, open text)
o What kind of business or industry do/did you work in? (for example,
hospital, elementary school, clothing manufacturing, restaurant) _______
(fill-in, open text)
o What year did you begin that job? [year – numerical fill-in]
o Are you currently employed in that job?
o No
o What year did you end that job? [year – numerical fill-in]
o Yes
22. 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?
o No
o Unsure
o Yes

Please answer the next group of questions based on your current (for current firefighters) or
most recent assignment (for former/retired firefighters).
23. What is/was your typical shift configuration?
o 24 hours on/24 hours off
o 24 hours on/48 hours off
o 24 hours on/72 hours off
o 48 hours on/96 hours off
o 24 hours on/24 hours off/24 hours on/24 hours off/24 hours on/4 days off (Kelly shift)
o 72 hours on/96 hours off
o 9 hours on/15 hours off
o 10 hours on/14 hours off
o 10 hours, 4 days per week
o 12 hours on/12 hours off
o 8 hours on, 5 days per week, unless deployed
o 5-6 (5-24 hour shifts, 6 days off)
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On-call
Volunteer, on-call continuously
Seasonally deployed
Other
o [If other] Please specify ________________
On average, how many calls do you/did you run in a shift?
o [dropdown with numerical options starting with 0-20] _____________
o 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?
o [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?
o [dropdown with numerical options raning from 0-24] _____________
Throughout your entire career, have you ever used Aqueous Film-Forming Foam (AFFF)?
o No
o Yes
o 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.
o No
o Yes
o Unsure
o [If yes] Please tell us more about this/these major event(s):
o Event 1: How would you classify the first event? [repeats for each event]
o Natural disaster
o Chemical
o Industrial/Factory
o Wildland
o Vegetation
o Structural
o Terrorist Event
o Other
o [If other] Please specify ______________________
o How long was your personal response to this event? [repeats for each event]
_______days OR [dropdown menu for days] ________ hours [dropdown menu
for hours]
o Was this a named event? (example, 9/11, Hurricane Katrina) [repeat for each
event]
o No
o Yes
o [If yes] What was this event commonly known as?
____________
o Event 2: How would you classify the second event? [repeats for each event]
o Natural disaster
o
o
o
o

24.

25.

26.

27.

28.

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Chemical
Industrial/Factory
Wildland
Vegetation
Structural
Terrorist event
Other
o [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]
o No
o Yes
o [If yes] What was this event commonly known as? _______
o
o
o
o
o
o
o

o
o

Health History
29. How often do you get an NFPA 1582 compliant or other comprehensive occupational physical exam?
o Annually
o Once every 2-3 years
o I do not routinely have an occupational physical exam
o Prefer not to answer
30. How often do you see a health care provider for a routine check-up?
o Annually
o Once every 2-3 years
o I do not see a health care provider routinely
o Prefer not to answer
31. [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?
o Yes
o [If yes] Approximately how old were you when you had your first test to check for
colon or rectal cancer? (numerical fill-in)
o [If yes] About how long has it been since your most recent test to check for colon or
rectal cancer?
o Within the past year (anytime less than 12 months ago)
o Within the past 2 years (1 year but less than 2 years ago)
o Within the past 3 years (2 years but less than 3 years ago)
o Within the past 5 years (3 years but less than 5 years ago)
o Within the past 10 years (5 years but less than 10 year ago)
o 10 years ago or more
o Unsure
o Prefer not to answer
o No
o Unsure
o Prefer not to answer
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32. [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?
o Yes
o [If yes] Approximately how old were you when you had your first PSA test?
(numerical fill-in)
o [If yes] How long has it been since your most recent PSA test?
o Within the past year (anytime less than 12 months ago)
o Within the past 2 years (1 year but less than 2 years ago)
o Within the past 3 years (2 years but less than 3 years ago)
o Within the past 5 years (3 years but less than 5 years ago)
o Within the past 10 years (5 years but less than 10 year ago)
o 10 years ago or more
o Unsure
o Prefer not to answer
o No
o Unsure
o Prefer not to answer
33. [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?
o Yes
o [If yes] Approximately how old were you when you had your first test to check for
cervical cancer? (numerical fill-in)
o [If yes] When did you have your most recent test to check for cervical cancer?
o Within the past year (anytime less than 12 months ago)
o Within the past 2 years (1 year but less than 2 years ago)
o Within the past 3 years (2 years but less than 3 years ago)
o Within the past 5 years (3 years but less than 5 years ago)
o Within the past 10 years (5 years but less than 10 year ago)
o 10 years ago or more
o Unsure
o Prefer not to answer
o No
o Unsure
o Prefer not to answer
34. [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?
o Yes
o [If yes] Approximately how old were you when you had your first mammogram?
(numerical fill-in)
o [If yes] How long has it been since your most recent mammogram?
o Within the past year (anytime less than 12 months ago)
o Within the past 2 years (1 year but less than 2 years ago)
o Within the past 3 years (2 years but less than 3 years ago)
o Within the past 5 years (3 years but less than 5 years ago)
o Within the past 10 years (5 years but less than 10 year ago)
o 10 years ago or more
12

o
o

Unsure
Prefer not to answer

o No
o Unsure
o Prefer not to answer
35. Have you ever been diagnosed with cancer?
o No
o Unsure if I have ever been diagnosed with cancer
o Yes
o [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)
13

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)?
o 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)
o 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)
o 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)
o 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)
o 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)
•

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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)
•

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•




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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)

36. Have you ever been told by a healthcare professional that you have the following conditions?
o Diabetes
o No
o Yes
o If yes, what type?
o Type 1
o Type 2
o Gestational
o Unsure
o High Blood Pressure
o No
o Yes
o High Cholesterol
o No
o Yes
o Overweight
o No
o Yes
o Obesity
o No
o Yes
o Rheumatoid Arthritis
o No
o Yes
o Asthma
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o
o
o
o
o
o
o
o

o
o
o
o
o

o No
o Yes
Emphysema
o No
o Yes
Chronic Bronchitis
o No
o Yes
Heart Disease (e.g. heart attack, heart failure, atherosclerosis)
o No
o Yes
Stroke
o No
o Yes
Sleep Apnea
o No
o Yes
Insomnia
o No
o Yes
Celiac Disease
o No
o Yes
Inflammatory bowel disease
o No
o Yes
o If yes, what type?
o Crohn’s Disease
o Ulcerative Colitis
o Unsure
o Other
o Please specify
Colorectal Polyps
o No
o Yes
Chronic Hepatitis (Hepatitis B, Hepatitis C)
o No
o Yes
Post-Traumatic Stress Disorder
o No
o Yes
Depression
o No
o Yes
Anxiety
o No
o Yes
17

Dementia
o No
o Yes
o Traumatic Brain Injury (concussion)
o No
o Yes
o Coronavirus Disease 2019 (COVID-19)
o No
o Yes
37. Have you ever experienced an injury resulting in 3 or more days away from work?
o No
o Yes
38. Have you ever experienced a smoke inhalation injury resulting in the need for medical care (such as
emergency department visit or health professional consultation)?
o No
o Yes
39. Do any of your biological children have a history of cancer?
o I do not have any biological children
o Unsure if my biological children have a history of cancer
o No
o Yes
o [If yes] For these biological children, where did the cancer(s) start (primary site)?
o
o Bladder
o Brain or Central Nervous System
o Breast
o Cervix
o Colon or Rectum
o Esophagus
o Hodgkin's Lymphoma
o Kidney
o Larynx (e.g., voice box, vocal cords)
o Leukemia
o Liver
o Lung
o Mesothelioma
o Multiple Myeloma
o Non-Hodgkin's Lymphoma
o Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
o Ovary
o Pancreas
o Prostate
o Skin: Melanoma
o Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or
Unknown
o Small Intestine
o Stomach
o

18

o Testis
o Thyroid
o Uterus/Endometrium
o Unsure which cancer (primary site)
o Other
o Please specify: _____
40. Do you have a family history of cancer among your other immediate biological (blood) relatives, including
mother, father, and/or sibling(s)?
o Unsure if I have a family history of cancer
o No
o Yes
o [If yes] For these blood relatives, where did the cancer(s) start (primary site)?
o Bladder
o Brain or Central Nervous System
o Breast
o Cervix
o Colon or Rectum
o Esophagus
o Hodgkin's Lymphoma
o Kidney
o Larynx (e.g., voice box, vocal cords)
o Leukemia
o Liver
o Lung
o Mesothelioma
o Multiple Myeloma
o Non-Hodgkin's Lymphoma
o Oral Cavity or Pharynx (e.g., lip, tongue, palate, tonsil, other parts of the mouth)
o Ovary
o Pancreas
o Prostate
o Skin: Melanoma
o Skin: Non-Melanoma (e.g., basal cell carcinoma, squamous cell carcinoma) or
Unknown
o Small Intestine
o Stomach
o Testis
o Thyroid
o Uterus/Endometrium
o Unsure which cancer (primary site)
o Other
o Please specify: _____
41. If answer to sex on question 9 is female (males will not see these questions): Have you ever been pregnant?
o No
o Yes
o If yes, how many times have you been pregnant? (numerical fill-in)
o How many of your pregnancies resulted in at least one live birth? (numerical fill-in)
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o How old were you when your first pregnancy occurred? (numerical fill in, unsure,
prefer not to answer)
o Have you ever breastfed?
o No
o Yes
o Approximately how many months did you breastfeed in total for
all births combined? ____months (numerical fill-in)
o Prefer not to answer

o Unsure
o Prefer not to answer
42. How old were you when you had your first menstrual period? (numerical fill-in) ______________
o Have never had a menstrual period
o Unsure
o Prefer not to answer
43. Has it been 12 months or more since you had your last menstrual period?
o No
o Yes
o How old were you when you had your last period? (numerical fill-in and unsure)
o Why did your menstrual periods stop?
o Currently pregnant or nursing
o Menstrual periods stopped naturally
o Surgery (e.g., hysterectomy or oophorectomy)
o Chemotherapy treatments
o Hormonal contraceptives (birth control pill, shot, patch, intrauterine device,
etc.)
o Unsure
o Other
o Please specify ______________
o 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)?
o No
o Yes
o How old were you when you began using these medications? (numerical
fill-in and unsure)
o Altogether, for how many months or years in total have you used these
medications? (numerical fill-in and unsure) ____months OR ______years
o How old were you when you stopped using these medications? (numerical
fill-in)
o Currently using
o Unsure
o N/A
o Unsure
o Prefer not to answer
44. Have you ever used hormonal contraceptives for two months or more for any reason (birth control, acne,
menstrual irregularity, endometriosis, polycystic ovarian syndrome, etc.)?
o No
o Yes
o How old were you when you began using hormonal contraceptives? (numerical fill-in
and unsure)
o Altogether, for how many months or years have you used hormonal contraceptives?
(numerical fill-in and unsure) ______months OR _______years
o How old were you when you stopped using hormonal contraceptives? (numerical fillin
o Currently using

20

o
o

o 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.
45. 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?
o Yes
o No
o Prefer not to answer
46. In a typical week, do you perform weight or strength training at least 2 days a week?
o Yes
o No
o Prefer not to answer
47. 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?
o Get a severe sunburn with blisters
o Have a moderate sunburn with peeling
o Burn mildly with some or no darkening/tanning
o Turn darker without sunburn
o Nothing would happen to my skin
o Do not go out in the sun
48. How many blistering sunburns have you had in your lifetime?
o 0
o 1-5
o 6-10
o 10 or more
Please answer the next group of questions based on your current and past uses with tobacco based products.
49. In your entire life, have you smoked 100 or more cigarettes (note, five packs is equal to 100 cigarettes)?
o Prefer not to answer
o No
o Yes, I currently smoke cigarettes
o On average, about how many cigarettes a day do you smoke? (numerical fill-in)
o At what age did you first start smoking regularly? (numerical fill-in)
o How many years have you smoked, not counting time periods when you had quit? (numerical fillin)
o Yes, I formerly smoked cigarettes
o On average about how many cigarettes a day did you smoke? (numerical fill-in)
o At what age did you first start smoking regularly? (numerical fill-in)
o How many years did you smoke, not counting time periods when you had quit? (numerical fill-in)
o How old were you when you last smoked cigarettes?
50. Did you ever use smokeless tobacco, such as chewing tobacco, snuff, or dip regularly for a year or longer?
o Prefer not to answer
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No
Yes, I currently use smokeless tobacco regularly
o On average, about how many dips per day do you use? (numerical fill-in)
o At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
o How many years have you used smokeless tobacco, not counting time periods when you had
quit? (numerical fill-in)
o Yes, I formerly used smokeless tobacco regularly
o On average about how many dips per day did you use? (numerical fill-in)
o At what age did you first start using smokeless tobacco regularly? (numerical fill-in)
o How many years did you use smokeless tobacco, not counting time periods when you had quit?
(numerical fill-in)
o How old were you when you last used smokeless tobacco?
Did you ever smoke cigars regularly for a year or longer?
o Prefer not to answer
o No
o Yes, I currently smoke cigars regularly
o At what age did you first start smoking cigars regularly? (numerical fill-in)
o How many years have you smoked cigars, not counting time periods when you had quit?
o Yes, I formerly smoked cigars regularly
o At what age did you first start smoking cigars regularly? (numerical fill-in)
o How many years did you smoke cigars, not counting time periods when you had quit?
o How old were you when you last smoked cigars?
Did you ever smoke pipes regularly for a year or longer?
o Prefer not to answer
o No
o Yes, I currently smoke pipes regularly
o At what age did you first start smoking pipes regularly? (numerical fill-in)
o How many years have you smoked pipes, not counting time periods when you had quit?
o Yes, I formerly smoked pipes regularly
o At what age did you first start smoking pipes regularly? (numerical fill-in)
o How many years did you smoke pipes, not counting time periods when you had quit?
o How old were you when you last smoked pipes?
Did you ever vape or use e-cigarettes regularly for a year or longer?
o Prefer not to answer
o No
o Yes, I currently vape or use e-cigarettes regularly
o At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
o How many years have you vaped or used e-cigarettes, not counting time periods when you had
quit?
o Yes, I formerly vaped or used e-cigarettes regularly
o At what age did you first start vaping or using e-cigarettes? (numerical fill-in)
o How many years did you vape or use e-cigarettes, not counting time periods when you had quit?
(numerical fill-in)
o 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] _____________
o
o

51.

52.

53.

54.

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o [If 0, skip questions 55-56]
55. During the past 30 days, on the days when you drank, how many drinks did you consume on average? [fill-in,
numerical text] __________
56. 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] __________
57. Has a health professional ever told you to consider reducing your alcohol use?
o Yes
o No
o Unsure
o 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:
58. Is there anything else you would like us to know? [narrative box]
Optional information you would like us to know about you.

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

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