0920-1348 NFR User Profile 18MAR2025

Form Approved

OMB No. 0920-1348

Exp. Date 04/30/2026

NFR User Profile

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 (0920-1348).

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 ______________

  

  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.”

• 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-__ __ __ __

[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.

• 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] ________________________