Every Woman Counts

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* 1. Full Name

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* 2. Date of Class or Even Attended

Date / Time

Date

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* 3. Date of Birth

Date / Time

Date

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* 4. Zip Code

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* 5. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 6. If you are 40 or older, have you had a mammogram?

Yes, I have less than 2 years ago

Yes, I have more than 2 years ago

No

Not Sure

Not 40 yet

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* 7. If you are 21 or older, have you had a pap test?

Yes, I have less than 2 years ago

Yes, I have more than 2 years ago

No

Not Sure

Not 21 yet

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* 8. Do you have health insurance?

Yes

No

Not sure

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* 9. By registering for this class, you agree that the EWC program can use your information for identification and future communication to support you in getting screened. Any information you share with the EWC program will be kept confidential and you can stop participating in EWC program activities at any time. EWC is a program of the California Department of Health Care Services.

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