Nebraska Colon Cancer Screening Program
FIT Kit Pilot Project

Provider FIT Kit Request Form

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1. Provider/Facility Name: (Required.)

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2. Provider/Facility Address: (Required.)

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3. Provider/Facility Phone: (Required.)

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4. Provider/Facility Email: (Required.)

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5. Name of staff member requesting FIT Kits:

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6. Number of FIT Kits being requested:

25

50

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7. Yes, we have read and understand the Clinic Responsibilities listed below:

Ensure each patient completes the FIT Kit Enrollment/Request Form, that will be attached to the FIT kit, prior to receiving a FIT kit:

FIT Kit Enrollment/Request Form (English)

FIT Kit Enrollment/Request Form (Spanish)

Match enrollment number and FIT Kit number

Submit patient FIT Kit Enrollment/Request Forms (can be mailed or faxed to NCP at 402-471-0913)

Ensure patients meet age requirements: 45-74 years of age (be at least 45 years of age and not have had their 75th birthday)

Provide instructions on how to complete the test and the importance of preventive screening

Write patient information and date sample collected on the vial and quarter sheet to be mailed back to the lab

Provide strong patient education on timely completion of FIT test and returning in the mail within 3 days of completing test

Name of Staff Member Representing Clinic:

Date of Acknowledgement of Clinic Responsibilities: