Cecil County Cancer Grant Participant Pre-Screening Form

Cecil County Cancer Grant Participant Pre-Screening Form

Please provide information regarding your operational membership, exposure, and demographics as requested below. If you would like to review the Cancer Screening information packet, please go to: https://heyzine.com/flip-book/9391d65880.html
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Eligibility: Are you a current or former volunteer or career member from a Cecil County fire company or the Cecil County Department of Emergency Services with current or past exposure related to firefighting duties or hazardous materials (HazMat) response duties?
Please select your gender and age range.
During your current or past service, what was your highest level of operational exposure?
How many total years have you served in Fire/EMS and/or HazMat operations?
Please indicate your smoking history in pack-years. Pack-years = packs smoked per day × number of years smoked. Example: 1 pack/day for 5 years = 5 pack-years
Have you ever had regular exposure to someone who uses tobacco products?
Do you have a direct family history of cancer (parent, grandparent, or sibling)?
Have you ever been diagnosed with or treated for cancer?
Within the past 5 years, have you received a blood-based cancer screening tool through this initiative, another program, or your physician that screens for multiple cancers at one time?
Are you currently experiencing any unexplained or persistent symptoms? Examples Include: persistent cough, fatigue, unexplained weight loss, unusual lumps, skin changes, or night sweats
Should be Empty: