First Responders Screening Program

Roswell Park has a longstanding commitment to helping first responders get screened for cancer and to provide the highest quality of cancer treatment care.

Please fill out the survey below that will ask you about your job as a first responder. We will not share your individual answers with anyone.

Please fill out the survey below that will ask you about your job as a first responder. We will not share your individual answers with anyone.

Should you have questions about your risk of developing cancer due to your work, please call us at 1-800-ROSWELL (1-800-767-9355) to schedule an appointment and identify yourself as a firefighter when making an appointment. These screenings are usually covered by insurance but you will be informed if there will be any expenses for you.

Fields marked with an asterisk * are required.

Your Information

About You

Are you filling this form out for yourself, or on behalf of someone else? *

About The Patient

Have you Has the patient ever been seen at Roswell Park? *

Your Patient's Contact information

Contact Methods

What is the best method to contact you the patient? *
Would you  the patient like to join our mailing list?

Demographic Questions

Sex & Gender

Race & Ethnicity

Education

What is the highest level of education you havethe patient has completed? *

Medical History

Metrics

feet inches
pounds

General Health

Have you been diagnosed with any of the following conditions by a doctor or other medical professional? * Mark all that apply.

Personal Cancer History

Cancer History

Have you ever been diagnosed with cancer? *

Smoking & Tobacco Usage

Smoking & Tobacco Use History

Have you ever smoked cigarettes? *
Have you smoked at least 100 cigarettes in your life? * 100 cigarettes is approximately 5 packs.
Do you currently smoke cigarettes? *
One pack contains 20 cigarettes
One pack contains 20 cigarettes
Have you ever used electronic cigarettes? * Also known as e-cigs or vape pens
How frequently do you use electronic cigarettes? *
For how long have you used, or did you use, electronic cigarettes? *
Have you used chewing tobacco at least 20 times in your life? * Brands such as Redman, Levi Garrett, Beech-Nut, etc.
Have you ever smoked any of the following substances? * Please choose all that apply.
How frequently do you smoke cigars? *
When you smoke cigars, do you inhale? *

Military Service

Military Service

Have youhas the patient ever served on active duty in the U.S. Armed Forces? * Active duty includes serving in the U.S. Armed Forces as well as activation from the Reserves or National Guard.
When did youthe patient serve on active duty in the U.S. Armed Forces? * Please choose all that apply.
During yourthe patient's military service, were youwas the patient ever exposed to environmental hazards such as Agent Orange, chemical warfare agents, ionizing radiation, or other potentially toxic substances? * Active duty includes serving in the U.S. Armed Forces as well as activation from the Reserves or National Guard.

Program Questions

First Responder Status

Have you ever been a first responder? *
Please select which type(s) of first responder you {{ responderPresent ? 'were' : 'are' }}: *
{{ responderPresent ? 'Were' : 'Are' }} you part-time or full time? *
In general, how would you describe the stress level of your job as a first responder? *

Firefighter-specific Questions

Which of the following roles {{ responderPresent ? 'did' : 'do' }} you typically perform on the scene of a structure fire? * Please check all that apply, current or past
Have you responded to any commercial fires?

Average Work Week

On an average week, {{ responderPresent ? 'did' : 'do' }} you perform administrative duties? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you spend time training? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you do fire response? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you do medical response? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you do hazmat response? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you do technical rescue? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you do fire prevention? *
On an average week, {{ responderPresent ? 'did' : 'do' }} you perform community outreach and education? *

Exposure

How often {{ responderPresent ? 'did' : 'do' }} you decontaminate your gear in the field after being on scene for a fire incident response? *
How often {{ responderPresent ? 'did' : 'do' }} you clean your gear when you return to the station after being on scene for a fire incident response? *
How often {{ responderPresent ? 'did' : 'do' }} you shower immediately (within an hour) after being on scene for a fire incident response? *

9/11

Did you respond to 9/11? *
Are you enrolled in the WTCHP? *

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

Second Job

Second Job

{{ responderPresent ? 'Did' : 'Do' }} you have a second job in addition to being a first responder? *
{{ responderPresent ? 'Did' : 'Do' }} you work in any of the following fields? * Select all that apply
{{ responderPresent ? 'Were' : 'Are' }} you exposed to second-hand smoke while at your other job? *