Today's date
(Required)
MM slash DD slash YYYY
Your name
(Required)
Dr.
Miss
Mr.
Mrs.
Ms.
Mx.
Prof.
Rev.
Prefix
First
Last
Your address
(Required)
Street Address or Box Number
City
State / Province / Region
ZIP / Postal Code
Your phone
(Required)
Your email
(Required)
Have you registered in our learning management system (LMS)?
(Required)
Yes
No
You do not need to register in our LMS to be eligible.
What is your LMS ID #?
Have you been a Massachusetts firefighter for at least 10 years or are you at least 40 years old?
(Required)
Yes
No
Retired, career, call, volunteer are all eligible as long as you are/were a firefighter for 10 years or are at least 40 years old.
What is your date of birth?
(Required)
Month
Day
Year
Early Detection Cancer Screening Options
PLEASE READ CAREFULLY in order to go to the location you want, for the cancer screenings you want.
If you are determined eligible, you have an option of locations for your cancer screenings.
(Required)
Worcester
Southbridge
Springfield
PLEASE READ CAREFULLY! Different locations offer different tests. Some vendors offer the ability to do all the tests in one day. Others do not. Select your location carefully! You can toggle between locations to get all the screenings you want. If you want to go to two locations, please fill out another form for the second location.
Please select cancer screening(s) offered at UMass Worcester:
(Required)
Chest CT Scan
Ultrasound
Mammogram (vendor offers Mammograms for females only)
PLEASE READ CAREFULLY! UMass Worcester cannot guarantee to conduct all tests on one day. You likely will need to go to this location more than once if you are looking for multiple tests.
Please select cancer screening(s) offered at UMass Harrington (Southbridge/Charlton/Webster).
(Required)
Chest CT Scan
Ultrasound
Mammogram (vendor offers Mammograms for females only)
PSA blood test (for individuals born male)
PLEASE READ CAREFULLY! UMass Harrington will offer to conduct cancer screenings on this list all in one day.
Please select cancer screening(s) offered at Mercy Memorial in Springfield.
(Required)
Chest CT Scan
Ultrasound
Mammogram
PSA blood test (for individuals born male)
PLEASE READ CAREFULLY! Mercy Memorial in Springfield will offer to conduct cancer screenings on this list all in one day.
Previous screenings that you have had through this early detection cancer program:
(Required)
None
CT Scan
Ultrasound
Mammogram
PSA blood test
Please do not apply for screenings you are not eligible for.
Previous CT Scan date
(Required)
MM slash DD slash YYYY
Please make sure it has been 3 years since your last CT Scan.
Previous ultrasound date
(Required)
MM slash DD slash YYYY
Please make sure it has been 3 years since your last ultrasound.
Previous Mammogram date
(Required)
MM slash DD slash YYYY
Please make sure it has been a year since your last mammogram.
Previous PSA blood test date
(Required)
MM slash DD slash YYYY
Please make sure it has been a year since your last PSA blood test.
Primary Care Provider Information (PCP)
You must have a Primary Care Provider to take part in this early detection cancer program. Your results are available to you but also sent to you Primary Care Provider.
Primary Care Provider (PCP) name
(Required)
PCP Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
PCP Phone
(Required)
Fax number
(Required)
Electronic signature
(Required)
I agree
Under the pains and penalties of perjury, I hereby certify that any and all information I provide regarding any cancer screenings in which I participate through the Massachusetts Fire Academy is true, accurate, and complete. I acknowledge and agree that I am solely responsible for the accuracy of such information and that any errors, omissions, or misrepresentations, whether intentional or unintentional, are my own responsibility. I further acknowledge, understand, and expressly consent that the Department of Fire Services may, at its sole discretion and at any time, record, maintain, and update screening-related information within my existing Learning Management System (LMS) profile and/or create an LMS profile when one does not exist. Such information shall be used exclusively for the purpose of tracking participation in screenings and related programs. I understand that this information will not be used for any other purpose unless required by law, regulation, or court order. By agreeing to this provision, I waive any claim or objection regarding the inclusion of such screening-related information in my LMS profile for the stated purpose. I certify that I am physically fit and have not been advised otherwise by a qualified medical person. I hereby certify that I have read this document, understand its content and agree to it under my own free will.