Logout Login | Contact Us




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:


© 2018 - IAFF