Cannot select choice! The maximum number of choices has been selected.Value removed!

Loading...

	COLOR	View equation
	Today's Date: * must provide value	TodayM-D-Y
	What event are you attending? * must provide value	Signup through website link/QR Enon Tabernacle Church (04/22/2023) Church of Christian Compassion (06/11/2023) Enon Fest (06/17/2023) Juneteenth @ Malcolm X Park (6/18/2023) St. Cyprian's Church (07/09/2023) Mexican Consulate (07/29/2023) St. Cyprian Church (08/13/2023) Dell Music Fest (CeCe Winan) (08/17/2023) Mexican Consulate Mobile Unit (08/26/2023) Dell-Jagged Edge (08/31/2023) St. Cyprian Church (09/10/2023) Colon Cancer Walk (09/16/2023) St. Thomas Aquinas Church (09/16/2023) Penn Treaty Park (09/17/2023) Men's Wellness Event @ Irvine Auditorium (09/30/2023) Local 22 Wellness Event (11/17/2023) Local 22 Wellness Event (12/01/2023) Signup through website link/QR Enon Tabernacle Church (04/22/2023) Church of Christian Compassion (06/11/2023) Enon Fest (06/17/2023) Juneteenth @ Malcolm X Park (6/18/2023) St. Cyprian's Church (07/09/2023) Mexican Consulate (07/29/2023) St. Cyprian Church (08/13/2023) Dell Music Fest (CeCe Winan) (08/17/2023) Mexican Consulate Mobile Unit (08/26/2023) Dell-Jagged Edge (08/31/2023) St. Cyprian Church (09/10/2023) Colon Cancer Walk (09/16/2023) St. Thomas Aquinas Church (09/16/2023) Penn Treaty Park (09/17/2023) Men's Wellness Event @ Irvine Auditorium (09/30/2023) Local 22 Wellness Event (11/17/2023) Local 22 Wellness Event (12/01/2023) reset
	Lab Corps Number
Contact Information
	First Name * must provide value
	Last Name * must provide value
	Date of Birth (for screening reminders) * must provide value	TodayM-D-Y
	Email Address * must provide value
	Mobile Phone Number
	Street Address
	City, State
	What is your zip code? * must provide value
	Is this correct? Name: ______ ______ DOB: ______ Email: ______ Mobile: ______ Address: ______, ______ ______ * must provide value	Yes No Yes No reset
Demographics
	Are you insured? * must provide value	Yes No Yes No reset
	What type of insurance do you have? * must provide value	Medicaid Medicare ACA Exchange Plan Private Insurance Don't Know Prefer not to answer Medicaid Medicare ACA Exchange Plan Private Insurance Don't Know Prefer not to answer reset
	Is your coverage through Independence Blue Cross (IBX)? * must provide value	Yes No Yes No reset
	Do you have any concerns about covering the cost of screening?	Yes No Yes No reset
	What is your race/ethnicity? * must provide value	American Indian/Alaska Native Asian, Pacific Islander Black (Non-Hispanic) Hispanic White Multiracial Other Prefer not to disclose American Indian/Alaska Native Asian, Pacific Islander Black (Non-Hispanic) Hispanic White Multiracial Other Prefer not to disclose reset
	What is your sex assigned at birth? * must provide value	Male Female Other Male Female Other reset
Eligibility Criteria
	How old are you? * must provide value
	Are you having any of these symptoms? Please select all that apply. * must provide value	Bleeding when you have a bowel movement or blood in your stool (bright red, black, or brick red) Change in bowel movements like diarrhea, constipation, or different consistency Persistent belly pain such as cramps, gas, or pain and/or feeling full or bloated Feeling like your bowel is not completely empty even after a bowel movement Nausea or vomiting Feeling tired more than usual Losing weight without trying None of the above Bleeding when you have a bowel movement or blood in your stool (bright red, black, or brick red) Change in bowel movements like diarrhea, constipation, or different consistency Persistent belly pain such as cramps, gas, or pain and/or feeling full or bloated Feeling like your bowel is not completely empty even after a bowel movement Nausea or vomiting Feeling tired more than usual Losing weight without trying None of the above
Personal History
	Have you ever been screened for colon or rectal cancer? * must provide value	Yes No Don't know Yes No Don't know reset
	When were you screened? * must provide value	200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023
	How were you screened? * must provide value	Stool blood test Stool DNA test Colonoscopy Sigmoidoscopy CT Colonography Don't know Stool blood test Stool DNA test Colonoscopy Sigmoidoscopy CT Colonography Don't know reset
	Did a healthcare provider tell you that you had a colon or rectal polyp? * must provide value	Yes No Don't know Yes No Don't know reset
	Did a healthcare provider tell you that you had colon or rectal cancer? * must provide value	Yes No Don't know Yes No Don't know reset
	When did your doctor recommend getting screened again? * must provide value	20002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025202620272028202920302031203220332034203520362037203820392040
	Have you ever been told you need a colonoscopy or at-home stool test by a healthcare provider? * must provide value	Yes No Yes No reset
	What are the reasons you didn't get screened?	Didn't think it was important Cost of test Couldn't take time off work Forgot Didn't know how to use the kit they gave me Afraid of the prep process for the colonoscopy Took too long to get scheduled Didn't have health insurance Provider doesn't take my insurance Didn't think it was important Cost of test Couldn't take time off work Forgot Didn't know how to use the kit they gave me Afraid of the prep process for the colonoscopy Took too long to get scheduled Didn't have health insurance Provider doesn't take my insurance
	Have you been diagnosed with any of the following? * must provide value	Ulcerative colitis Inflammatory bowel disease Crohn's disease Cancer None of the above Ulcerative colitis Inflammatory bowel disease Crohn's disease Cancer None of the above
Family History
	Have any of your immediate family members ever had colon cancer or rectal cancer? * must provide value	Parent (mother/father) Child Brother or sister Grandparent Other relative (aunt, uncle, cousin) No family history Parent (mother/father) Child Brother or sister Grandparent Other relative (aunt, uncle, cousin) No family history
	At what age was the youngest person in your family diagnosed? * must provide value
	Total number of family members diagnosed with colon or rectal cancer * must provide value
	Does your family have a known history of hereditary colon or rectal cancer syndrome such as one of the following? * must provide value	Lynch Syndrome (also known as hereditary non-polyposis colon cancer, or HNPCC) Familial adenomatous polyposis (FAP) Other No Don't know Lynch Syndrome (also known as hereditary non-polyposis colon cancer, or HNPCC) Familial adenomatous polyposis (FAP) Other No Don't know
	Did you fill this quiz out for yourself? * must provide value	Yes No Yes No reset
	If you are eligible, would you like us to mail you a free test kit? * must provide value	Yes No Yes No reset
	Would you like the results of your at-home test to be sent to your doctor? * must provide value	Yes No Yes No reset
	Please provide us with your doctor's name, address, and telephone number.
	Primary Care Doctor's Name
	Primary Care Doctor's Address
	Primary Care Doctor's Phone Number
	How did you first hear about the Colorectal Cancer Alliance? * must provide value	Web search (Google, etc) CCA recommendation Written materials in an office At an event Someone I know Another organization Other Web search (Google, etc) CCA recommendation Written materials in an office At an event Someone I know Another organization Other reset
	How did you hear about the colorectal cancer screening program?	Saw or heard an advertisement - website, social media, radio Web search (Google, etc) CCA recommendation Written materials in an office At an event Someone I know Another organization Other Saw or heard an advertisement - website, social media, radio Web search (Google, etc) CCA recommendation Written materials in an office At an event Someone I know Another organization Other
	Is the patient eligible to receive a FIT?	Yes No Yes No reset
	Date of Test Pickup (FOR OFFICE USE ONLY)
	How did the participant receive their FIT kit?	Mail In-person No-show Mail In-person No-show reset
	Result of Test (FOR OFFICE USE ONLY)	Returned - Positive Returned - Negative Pending - Unreturned Withdrawal - Colonoscopy through provider No longer interested Returned - Positive Returned - Negative Pending - Unreturned Withdrawal - Colonoscopy through provider No longer interested reset
	NAVIGATION IF RETURNED AND POSITIVE:	Insured - Follow-up with PCP Under or uninsured - Navigated to colonoscopy Insured - Follow-up with PCP Under or uninsured - Navigated to colonoscopy reset
	Result Letter Sent	Check when complete Check when complete reset
	If no longer interested, reason:
	Attempts at communication	Letter mailed, no response Called once, no response Called multiple times, no response Text sent, no response Successful communication Letter mailed, no response Called once, no response Called multiple times, no response Text sent, no response Successful communication reset
	Primary Navigator	CCA Penn CCA Penn reset
	Additional Notes	Expand
	Case Closed?	Yes No Yes No reset
Submit