Attachment C1_A Screening Eligibility (SEA) Form - FINALv2

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.

Please complete Section A of this form to help us determine your eligibility. If you are eligible, we will send information to you in the next few weeks about colorectal cancer screening and this program. If you do not want to receive this information, let us know by checking the box in Section C.

Whether or not you are eligible for this program, please also answer the questions about yourself in Section B and return the completed form in the postage paid envelope provided.

A. I am 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? Yes No	B-4. Which language do you prefer to speak? English Spanish Other
B-2. Do you consider yourself to be . . .? Check all that apply. American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White	B-5. What is your highest level of education? Less than high school High school graduate or GED Some college or 2-year degree 4-year college degree or a graduate degree
B-3. Are you . . .? Single Married Divorced, separated, widowed	B-6. How would you describe your health? Excellent Very Good Good Fair Poor

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.