See, Test & Treat - Prescreening Questionnaire As See, Test & Treat continues to demonstrate its impact on communities across the United States; we are experiencing an overwhelming response to host programs in many communities.The 2019 See, Test & Treat RFA period will open on Friday, June 1, 2018 and close at 5:00 pm CT on Friday, August 31, 2018. All sites wanting to host a program and apply for See, Test & Treat funding in 2019, must submit the Pre-Screening Questionnaire and Program/Grant Application by the August 31, 2018 deadline. For repeat programs, please fill out the Program/Grant Application ONLY. That application can be found here.The CAP Foundation will continue to offer grants of up to $20,000 to support See, Test & Treat program expenses that other grants and in-kind donations do not cover. As See, Test & Treat continues to expand, we look to repeat programs to become more self-sustaining and actively pursue other sources of funding in addition to securing in-kind donations in the areas of refreshments/food, supplies, promotion and publicity.Your responses to these questions will help determine if you are ready to host a See, Test & Treat program. If you answer No to any of the questions, contact CAP Foundation Programs Staff for potential solutions (Julia Rankenburg at 847-832-7931 or jranken@cap.org).Requirements of all See, Test & Treat programs:* CAP member pathologist program leader(s) or co-leaders* Underserved patient population* Hospital or clinic program host site/location* Partnership between pathologists and Multispecialty Volunteer- clinical team* Host site for care of patients* Capacity to provide a pelvic and breast exam, Pap test and mammogram to eligible women.* Provision of same-day Pap test results delivered personally to patients on-site.* Provision of same day or prompt mammogram results (within one week)Application Requirements:* Must be a CAP member to apply* Must be able to meet all program requirements listed above Question Title * 1. Contact Information - Only CAP members may apply for a See, Test & Treat Grant Name Company Address Address 2 City/Town 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 ZIP/Postal Code Country Email Address Phone Number Question Title * 2. Host Site Name See, Test & Treat® (STT) is a US-based screening program for women meeting the eligibility requirements as defined by the ACS/ACOG screening guidelines and face healthcare disparities, socioeconomic or other barriers to accessing routine healthcare. STT is not for women currently accessing care through the host hospital or clinic. Question Title * 3. Have you identified a local community population with demonstrated need for a See, Test & Treat® program? Yes No Yes No If no, please explain Question Title * 4. Are you a current CAP member or are you working with a CAP member? Yes No Yes No If no, please explain Question Title * 5. Are you willing to lead or co-lead the planning, coordination, and on-site execution of a See, Test & Treat® program? Yes No Yes No If no, please explain Question Title * 6. Do you have the support of your hospital or clinic or the commitment from a local healthcare facility to host a one-day screening program? Yes No Yes No If no, please explain Question Title * 7. Is the host site a 501(c)3 organization? Yes No Yes No If no, please explain Question Title * 8. If no to question 6, can you identify a 501(c)3 organization to act as recipient and fiduciary of CAP Foundation grant funding? Yes No Yes No If no, please explain Question Title * 9. Can you secure the volunteerism and support of the following stakeholders to assist with planning and hosting your See, Test & Treat® program: Yes No Host site (Hospital/Clinic/Community Health Center) Host site (Hospital/Clinic/Community Health Center) Yes Host site (Hospital/Clinic/Community Health Center) No Administration/Medical Director Administration/Medical Director Yes Administration/Medical Director No Pathologist/Pathology Department Pathologist/Pathology Department Yes Pathologist/Pathology Department No Laboratory Laboratory Yes Laboratory No Gynecologist/Gynecology Department Gynecologist/Gynecology Department Yes Gynecologist/Gynecology Department No Radiologist/Radiology Department Radiologist/Radiology Department Yes Radiologist/Radiology Department No Medically Certified Interpreters Medically Certified Interpreters Yes Medically Certified Interpreters No Patient Advocate/Community Outreach Department Patient Advocate/Community Outreach Department Yes Patient Advocate/Community Outreach Department No Patient Registration Patient Registration Yes Patient Registration No Financial Aid Department Financial Aid Department Yes Financial Aid Department No Public Relations/Marketing/Communications Public Relations/Marketing/Communications Yes Public Relations/Marketing/Communications No Question Title * 10. Do you have the capabilities in your hospital, clinic or nearby facility to provide the following services with same-day results: Yes No Clinical pelvic exam Clinical pelvic exam Yes Clinical pelvic exam No Pap test Pap test Yes Pap test No Clinical breast exam Clinical breast exam Yes Clinical breast exam No Screening mammography Screening mammography Yes Screening mammography No Question Title * 11. For women who are diagnosed with abnormal cervical or breast results, does the host site have the capability to either provide same-day or timely additional procedures or tests for the following: Yes No Colposcopy Colposcopy Yes Colposcopy No LEEP LEEP Yes LEEP No Mammogram (additional diagnostic views) Mammogram (additional diagnostic views) Yes Mammogram (additional diagnostic views) No Question Title * 12. For women who present with abnormal cervical or breast results, is there a referral system in place for connecting women to necessary care and treatment? Yes No Yes No If no, please explain Question Title * 13. Can you secure culturally sensitive, patient-centered, translated education? Yes No Yes No If no, please explain Question Title * 14. Will your See, Test & Treat® program include culturally sensitive, patient-centered health information on any of the following topics: Yes No What is a Pap test? What is a Pap test? Yes What is a Pap test? No Why is cervical cancer screening important in maintaining a women’s health? Why is cervical cancer screening important in maintaining a women’s health? Yes Why is cervical cancer screening important in maintaining a women’s health? No What is a mammogram? What is a mammogram? Yes What is a mammogram? No Why is having a mammogram important in maintaining a women's health? Why is having a mammogram important in maintaining a women's health? Yes Why is having a mammogram important in maintaining a women's health? No Demonstration or information about how to perform a self-breast examination. Demonstration or information about how to perform a self-breast examination. Yes Demonstration or information about how to perform a self-breast examination. No The opportunity to view slides of healthy and abnormal specimens with a pathologist or pathology resident. The opportunity to view slides of healthy and abnormal specimens with a pathologist or pathology resident. Yes The opportunity to view slides of healthy and abnormal specimens with a pathologist or pathology resident. No Opportunity for patients to discuss their results with a pathologist. Opportunity for patients to discuss their results with a pathologist. Yes Opportunity for patients to discuss their results with a pathologist. No Education about healthy lifestyle. Education about healthy lifestyle. Yes Education about healthy lifestyle. No Education or demonstrations about healthy nutrition. Education or demonstrations about healthy nutrition. Yes Education or demonstrations about healthy nutrition. No Information about eligibility requirements for financial aid or charity program, state or federal program or health insurance marketplace exchange. Information about eligibility requirements for financial aid or charity program, state or federal program or health insurance marketplace exchange. Yes Information about eligibility requirements for financial aid or charity program, state or federal program or health insurance marketplace exchange. No Other (please specify) Done