Colorectal Cancer (CRC) Screening Initiative Registration Survey

Thank you for your interest in participating in the Colorectal Cancer Screening Initiative. Please complete the following survey to help us understand your program's current screening practices and goals.

Please Note: Funding Eligibility Requirements

Complete a Readiness Assessment Tool (separate from this registration form)
Attend both virtual workshops on July 29 and 30, from 10:00am-12:00pm PT - no travel necessary
Required reporting at 3, 6, and 12 months

1.Program Information
Please provide the following information:(Required.)

Program Name

Primary Program Contact Name

Primary Program Contact Email Address

Primary Program Contact Phone Number

2.Quality Improvement (QI) Contact Information
Please provide the following information:(Required.)

QI Contact Name

QI Contact Email Address

QI Contact Phone Number

3.Initiative Champion Information
Please provide the following information. If the Initiative Champion is the same as the Primary Program Contact, please indicate "Same as Program Contact."
(Required.)

Initiative Champion Name

Initiative Champion Email Address

Initiative Champion Phone Number

4.Can your program's Initiative Champion commit to attending the required virtual workshops on July 29 and 30, from 10:00am-12:00pm PT? No travel necessary.
(Required.)

Yes

Unsure

5.What electronic health record (EHR) does your program utilize?(Required.)

6.What data analytics and/or population health platform(s) does your program currently utilize, if any?

7.By how many percentage points does your program aim to increase its CRC screening rate within the next 12 months?
Example: Current rate 40%, goal rate 50%, enter 10.(Required.)

8.Has your program ever participated in a mailed FIT population health screening initiative?(Required.)

Yes

Unsure

9.Which FIT test does your program currently use?(Required.)

10.Does your program currently utilize Cologuard for colorectal cancer screening?(Required.)

Yes

Unsure

11.Please briefly describe your clinic’s quality improvement (QI) structure.
Include your primary QI methodology, if applicable (e.g., Plan-Do-Study-Act [PDSA], Lean, Six Sigma, or another approach).(Required.)

12.How experienced is your clinic staff with quality improvement (QI) efforts?(Required.)

Highly experienced – We have a dedicated QI team and a formal QI plan.

Fairly experienced – We are familiar with QI principles but do not formally conduct QI activities.

Not very experienced – We have limited knowledge of QI and do not currently conduct QI activities.

13.Prior to the start of this project, which of the following applied to your clinic?(Required.)

We used health information technology (HIT) to perform data analytics and reporting to monitor colorectal cancer screening rates.

We had a QI team focused on improving colorectal cancer screening rates.

None of the above

14.What other quality improvement (QI) activities is your clinic currently undertaking or planning to undertake?
Please include both current and planned initiatives.(Required.)

15.Additional Comments
Please provide any additional information about your CRC screening program, goals, or readiness to participate in this initiative.

After your program submits this application, the Initiative Champion will receive a Readiness Assessment Tool. To be considered for participation, the completed assessment must be returned to anna.knight@ihs.gov within 14 days with the subject line: “Completed Readiness Assessment Tool – [Clinic Name].”