Event Screening Request Form

 
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1. (Please read all instructions carefully.)
The Office of Community Health has provided diabetes and prostate cancer screening in the community for several years. We also offer Teen Talk sessions to encourage teens to make healthy lifestyle choices. We have built a solid reputation of excellence and have established trust within the community. As a result, we receive numerous requests to provide screening at various community events throughout the year.

It is our goal to meet the needs of our community however, we cannot accommodate all requests. The following information will help you to understand our guidelines and whether or not our screening programs are right for your organization.

Prostate Cancer Screening Eligibility
Men who meet the following criteria are eligible for screening for prostate cancer:
• African American men age 40. If family history (father, brother, son), screening at age 35
• All other men age 50 and older
• All other men with a family history of prostate cancer can be screened at age 45

Diabetes Screening Eligibility
Individuals are eligible for type 2 diabetes testing if they meet the following criteria:
• Non-diabetic adults age 18-44 must be at risk for pre-diabetes or “high risk” for developing type 2 diabetes.
• Non-diabetic adults age 45+ are eligible for testing regardless of risk
Risk is determined by completing the American Diabetes Association risk assessment card. We will not screen anyone who has been previously diagnosed with Diabetes.

Teen Talk Sessions
Teens ages 13-18 are eligible to participate in 1-1 1/2 hour sessions. The sessions cover self-esteem, peer pressure/refusal skills, goal setting and decision making. The goal of the session is to help teens make good choices and prevent teen pregnancy.
To schedule a Teen Talk Sessions, please call 296-3764.

Notice of Event Guidelines
The Office of Community Health can better accommodate your request if it is received at least 2 months prior to the event. Please be advised that submitting a request 2 months prior to your event does not guarantee that we will be able to accommodate your request.

Screening Requirements: To ensure the safety and privacy of our patients the following are mandatory requirements for screening:
• Minimum of two tables and eight adult-sized chairs
• Indoor area to collect blood specimens. No blood will be drawn outside
• Adequate lighting to ensure the safety of those being screened
• Screening area must be setup in a space conducive to protecting the privacy of those persons being screened
• Screening area must be clean and the facility must have clean restrooms.

If these requirements are not met we reserve the right to cancel participation in the event.

Promotional Materials: All promotional materials must be reviewed by Palmetto Health prior to distribution. Please contact our office at 296-3070 for further details.

Number of individuals expected to attend
The Office of Community Health requires that you have 30 eligible individuals registered for the screening at least 2 months prior to your event. Please inform your event participants that they must call CARE CALL 296-2273 to register for the free screening. Only those confirmed by calling CARE CALL for the PSA/diabetes screening count towards the 30 eligible minimum. If we are unable to assist you with your requested event date, you may request an alternate event date.

If your organization fails to register 30 eligible individuals, the Office of Community Health reserves the right to cancel its participation in your community event. The 30 eligible individuals can be a combination of those who qualify for diabetes and prostate cancer screening.

If the Office of Community Health is unable to provide screenings for your event, we may be able to provide information regarding diabetes, prostate cancer, nutrition and/or information about our programs and services.





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