OPFFA/IAFF Parkinson's Disease Survey

Confidentiality Statement

This survey and any files or personal information transmitted within it are confidential and intended solely for the use of the individuals or entity to whom they are addressed. If you have received this survey in error please notify the system manager. This survey contains confidential information and is intended only for the Ontario Professional Fire Fighters Association, Occupational Disease Committee, processed through the Canadian Office of the International Association of Firefighters. If you are not the intended participant you should not disseminate, distribute or copy this survey or its contents.

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* 1. In which Canadian fire department did you work as a full-time fire fighter?

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* 2. How many years of service do you have?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 3. How many years of service did you have when you were diagnosed with Parkinson's Disease?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 4. At what age were you diagnosed with Parkinson's Disease?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 5. What age were you when you first noticed the symptoms of Parkinson's Disease?

100

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 6. What type of Parkinson’s like conditions or symptoms (neurologic condition) have you been diagnosed with?

Dementia with Lewy Bodies

Corticobasal Degeneration

Essential Tremor

Drug-induced Parkinson's

Multiple System Atrophy

Progressive Supranuclear Palsy

Vascular Parkinsonism

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* 7. Was a Worker's Compensation claim filed?

Yes

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* 8. If a claim was allowed, was it denied?

Claim was allowed

Claim was denied

N/A (no claim filed)

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* 9. Were you involved in a specific incident (chemical exposure, industrial fire or hazmat incident) that you documented as an exposure that you believe is a contributing factor to your diagnosis? If yes can you explain further or list the chemicals, you were exposed too?

Yes (please explain)

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* 10. Have you worked with other firefighters who have been diagnosed with Parkinson’s or other neurological diseases?

Yes

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* 11. Are you aware of any other retirees from your department who have also been affected by Parkinson’s Disease?

Yes

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* 12. Are you aware of any firefighters from your department who passed away from complications of a neurological disease?

Yes

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* 13. May we contact you if we have any follow-up questions based on your survey responses?

Yes (please provide name, email address or phone number)

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* 14. Thank you for your participation. The information collected through this survey will be kept confidential. If you have any comments or other information you would like to share, please use the space below. Please be sure to click "Done" when you are finished.