80% Pledge Question Title * 1. Contact Information First Name * Last Name * Organization * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Website Email * 2nd Contact Person Email (optional) Twitter Handle Question Title * 2. What is the focus of your organization's colorectal cancer screening programming? (Select all that apply) National Local (one state or less than one state) None Regional (parts of multiple states) If regional, please name the state(s) in addition to the state selected above. Question Title * 3. Please select from this list all labels that you feel best describe the organization you represent. (Select all that apply) Academic Institution Cancer Center Cancer Coalition/Partnership (including Comprehensive Cancer Programs) City/County Health Department Community Health Center/FQHC Community Organization/Local Non-profit Consulting Group Employer Faith-based Organization Federal Agency Gastroenterology Practice Health Plan Hospital/Medical Center/Health System (hospital care, which can include primary care) Local/State Elected Leader Medical Professional Society (National) Medical Professional Society (State) National Non-profit Pharmaceutical/Medical Test/Device Company Primary Care Association Primary Care Practice/System (primary care only) Quality Improvement Organization State Health Department Survivor-based Organization Tribal Organization Other (please specify) Question Title * 4. The National Colorectal Cancer Roundtable sends weekly emails to partners who have signed the pledge about new resources and learning opportunities directly related to the 80% by 2018 initiative. We will not intentionally sell, share or distribute your personal information to third parties. You may opt out of emails at any time. All partners will receive a welcome email and an invitation to participate in our 80% by 2018 Partner Survey each summer or early fall. If you would prefer not to receive additional emails, please indicate that here: Please do not send me 80% by 2018 email updates. Question Title * 5. Please enter the name of the American Cancer Society representative who referred you to 80% by 2018. (If applicable) Question Title * 6. Does your organization measure or track the colorectal cancer screening rate of your patient population or workforce? Yes No Next
