Form #2 Form #2 Screening Eligibility Assessment (SEA) Form

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Colorectal Cancer Screening Eligibility Assessment

We are evaluating a new program for men and women who are 50-79 years of age and are eligible for colorectal cancer screening. You are receiving this form because our records show that you may be eligible for this program. Your answer to Section A of this form will help us determine your eligibility.

If you are eligible, in the next few weeks, we will send information to you about colorectal cancer screening and this program unless you check the box in Section C to tell us you do not want to receive this information. Whether or not you are eligible for this program, please answer the questions about yourself in Section B. When you have completed this form, please return it in the postage paid envelop provided.

A. I may not eligible for colorectal cancer screening through this program because: (Check all that apply)

I am not between 50 and 79 years of age

I had a recent screening test (a colonoscopy in the last 10 years, a stool blood test at home in the last

year, a flexible sigmoidoscopy in the last 5 years, or a barium enema x-ray in the last 5 years)

I have previously been diagnosed as having colorectal cancer

Other reason (Specify)_____________________________________________________________________

B. Please answer the following questions about yourself.

B 1. Do you consider yourself to be Hispanic or Latino? B4. Which language do you prefer to speak?

Yes No English Spanish Other

B2. Do you consider yourself to be: B5. What is your highest level of education?

(Check all that apply)

American Indian or Alaskan Native Some high school

Asian High school graduate or GED

Black or African American Some college or Associate’s degree

Native Hawaiian or Pacific Islander College degree or above

White

Other ________________________ B6. How would you describe your health?

B3. Are you: Poor

Fair

Single Good

Married Very Good

Divorced, separated, or widowed Excellent

C. Please do not send me information about colorectal cancer screening or this program.

(Note: If you do not want to receive this information, you may also call 610-969-XXXX and leave a message. Please identify yourself using the survey number below rather than using your name.)

Survey No. □□□□□□□

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the form. 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. Form Approved: OMB Number 0935-XXXX Exp. Date xx/xx/20xx. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.