IAFF

Username:

Password:

If your family member was or is a member of the IAFF and was diagnosed with cancer please take a few minutes to answer the following questions. If they were diagnosed with more than one type of cancer please complete a separate form for each cancer. A representative from the IAFF will be contacting you to further discuss the cancer diagnosis. The conversation and any information you provide will be kept confidential. The information related to the cancer will be included in the IAFF Cancer Registry.

Name of person completing form

Relationship to fire fighter

Fire fighter's name

Fire fighter's birth date

Is the fire fighter living?

Yes No

If no what is the date of death?

What type of cancer does/did the fire fighter have?

Other:

When was the cancer diagnosed?

What is/was the fire fighter's most recent address?

Address:

City/Town:
State/Province:
Zip:

What is the fire fighter's telephone number?

Was the fire fighter at the above address when the cancer was diagnosed?

Yes No Not known

If no what was the address?

Address:

City/Town:
State/Province:
Zip:

What is the best way for us to contact you to obtain additional information regarding the fire fighter's cancer?

Address

Address:

City/Town:
State:
Zip:

Telephone
What is the best number?

Email:

International Association of Fire Fighters
1750 New York Ave., NW, Washington, DC 20006 • 202.737.8484 • 202.737.8418 (Fax)
Copyright © 2010 International Association of Fire Fighters. Last Modified: 3/12/2010