Today's date(Required)
Your name(Required)
Your address(Required)
Have you registered in our learning management system (LMS)?(Required)
You do not need to register in our LMS to be eligible.
If you do not know your LMS ID #, please provide the last 4 digits of your social security number.
Have you been a Massachusetts firefighter for at least 10 years or are you at least 40 years old?(Required)
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)

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)
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)
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)
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)
PLEASE READ CAREFULLY! Mercy Memorial in Springfield will offer to conduct cancer screenings on this list all in one day.
Please select cancer screening(s) offered through our mobile vendor at Bridgewater Academy.(Required)
PLEASE READ CAREFULLY! We are ONLY offering an ultrasound and PSA. This will be offered on March 4th, 5th OR 6th ONLY.
Previous screenings that you have had through this early detection cancer program:(Required)
Please do not apply for screenings you are not eligible for.
Previous CT Scan date(Required)
Please make sure it has been 3 years since your last CT Scan.
Previous ultrasound date(Required)
Please make sure it has been 3 years since your last ultrasound.
Previous Mammogram date(Required)
Please make sure it has been a year since your last mammogram.
Previous PSA blood test date(Required)
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.
PCP Address(Required)
Electronic signature(Required)
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.