Nebraska Department of Health and Human Services
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We Need Some Important Feedback From You!

This information will only be used to help us in developing the Nebraska Colon Cancer Screening Program and as described below. This information will not be shared with any other parties for any reason.
1) What is your age? 


If you specified "Other" above, please enter your age here: 
2) What is your race? 
3) Are you of Hispanic origin? 
4) Have you ever had a test for colorectal cancer? 
5) If yes, what type of test did you do?


If you specified "Other" above, please enter the type here: 
6) Is there another person in your household over the age of 50?
7) If yes, are they
8) Has the other person been tested for colorectal cancer?
9) If yes, what type of test did they do?


If you specified "Other" above, please enter the type here: 
10) For others in your household, what would make it worth their time to complete the test? Is there a gift, prize or something else that would make them more likely to complete the colorectal cancer screening test?
11) If yes, please give us some examples:
12) What would make it worth your time to complete the test? Is there a gift, prize or something else that would make you more likely to complete the colorectal cancer screening test?
13) If yes, please give us some examples:
14) If colorectal cancer screeenings were available, would you enroll to receive colorectal cancer screening?
15) If no, why not?
16) If a program were available to others in your household do you think they would you enroll to receive colorectal cancer screening?
17) If no, why not?
18) Are you currently an EWM client?
19) Please tell us your income level:



20) Every Woman Matters will be bringing together seperate groups of men and women 50 years of age and older to help us understand their feelings about colorectal cancer screening. If a group discussion were held in your area would you be willing to participate and share your thoughts about program services?
21) Would you be willing to provide input on program messages, materials and ideas individually through mailed surveys from time to time?
If you answered yes to either question 19 or 20 above, please provide us with your name and address.
22) Name:
23) Address:
24) City:
25) State:
26) Zip:
27) Phone:
28) Best time to call: 
29) E-mail: