Annual Aggregate Data on Medically Ineligible Clients Fo

ATTACHMENT 5

ANNUAL AGGREGATE DATA ON MEDICALLY INELIGIBLE CLIENTS FORM

Form Approved

OMB No. 0920-xxxx

Exp. Date_________

Colorectal Cancer Screening Demonstration Program (CRCSDP)

Annual Aggregate Data on Medically Ineligible Clients

Public reporting burden of this collection of information is estimated to average one hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).

Please provide counts for each of the rows that apply, only for those persons who are assessed as medically ineligible (see categories below), but who otherwise meet the eligibility requirements for the CRCSDP (i.e., low income, uninsured or underinsured, age requirements, and geography).

Program:
Reporting Period:

Yearly submission dates

Information on clients deemed ineligible from	Data due to CDC
March 1, 2006 –August 31, 2006	Dec 1, 2006
September 1, 2006 –August 31, 2007	Dec 1, 2007
September 1, 2007 – August 31, 2008	Dec 1, 2008

Counts of unique, financially eligible¹ clients deemed medically ineligible

Reason for ineligibility		Count
Clients with medical conditions such as Inflammatory Bowel Disease (e.g. Ulcerative colitis, Crohn’s colitis) referred for appropriate management outside of the program.
Clients with a suspected genetic syndrome (i.e. familial adenomatous polyposis [FAP], hereditary adenomatous polyposis colorectal cancer [HNPCC]) referred for appropriate genetic testing/counseling outside the program.
	Clients tested or counseled for, but not diagnosed with a genetic syndrome, who return to the program for screening.
Clients who are symptomatic at enrollment and are immediately referred for medical evaluation outside of the program (Note: Each program has defined their own set/list of symptoms requiring medical evaluation).
Clients deemed medically ineligible because of a personal history of colorectal cancer previously diagnosed outside of the program (Note: This will only apply to some programs).
Clients deemed ineligible because of a personal history of adenomatous polyps previously diagnosed outside of the program (Note: This will only apply to some programs).
Clients who are found at enrollment to have had an initial positive CRC screening test performed outside of the program and are now seeking diagnostic services (diagnostic referrals not accepted in the CRCSDP).

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