First Responders Screening Program

Your Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? * Yes No

Patient MRN *

How did you hear about Roswell Park?

Please explain *

Your Patient's Contact information

Contact Methods

Your Patient's Phone number * (###-###-####)

Alternate phone * (###-###-####)

Your Patient's Email Address *

What is the best method to contact you the patient? * Phone call Email

Best time to call *

Would you the patient like to join our mailing list? Yes No

In the event of cancellation, are youis the patient interested in same or next day appointments? * Yes No

Program Questions

First Responder Status

Have you ever been a first responder? * Yes, I currently am Yes, I previously was No

Please select which type(s) of first responder you have been: * Police Firefighter Emergency Medical Technician (EMT) Other

Please describe the type of first responder *

About how many years have you served as a first responder? *

In a typical month how many days do you work as a first responder?

On average, how many hours do you work in a shift?

Police

Firefighter-specific Questions

Approximately how many times a year do you go interior on structure fires?

Approximately how many fire runs do you participate in per month?

Which of the following roles do you typically perform on the scene of a structure fire?

Please check all that apply, current or past.

Non-Interior / Probationary Member Interior Firefighter Driver Operator / Engineer Incident Command / On-scene Management

Have you responded to any commercial fires? Yes No

Please list all the commercial fires you have responded to

EMT

9/11

Did you respond to 9/11? Yes No

Are you enrolled in the WTCHP? Yes No

Please take a moment and check your eligibility for the WTCHP.

Smoking

Smoking Status

Are you exposed to second-hand smoke while at work? * Yes No

Medical Screening

In the last five years have you had a chest x-ray? Yes No

Insurance & Physician Information

Your Patient's Insurance Information

Are you covered by any kind of health insurance or some other kind of health plan? Yes No

Primary insurance provider *

ID number * (Letters and Numbers only)

Secondary insurance provider

ID number (Letters and Numbers only)

Please choose a preferred location for the appointment * Roswell Park Niagara Falls

6934 Williams Road, Suite 300, Niagara Falls, NY 14304

Roswell Park Main Campus

Elm and Carlton Streets, Buffalo, NY 14263

Your Patient's Physician Information Optional

Primary physician

Primary physician's phone (###-###-####)

Referring physician

Referring physician's phone (###-###-####)

Your Patient's Residential Address