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Thank you for reaching out for more information and to schedule a cancer screening and receive Patient Navigation Services through ScreenNJ.

We have a few questions for you in the short, 2-minute, form below. Once you submit the questionnaire, a Patient Navigator will reach out to you within 72 hours. If you have additional questions, please call 833-727-3665, dial extension 1 for Spanish, 2 if in North NJ, 3 if in Central NJ, 4 if in South NJ or 5 for general information.
Preferred language*
- English
- Spanish
- Arabic
- Chinese
- French
- Gujarti
- Haitian Creole
- Hindi
- Korean
- Polish
- Portuguese
- Russian
Please let us know how you would like the ScreenNJ team to help*
- I would like to be vaccinated against HPV
- I would like more information about cancer prevention education and screenings
- I would like to schedule a cancer screening, but not at the mobile health unit
- I would like to register for a mobile health unit event
Disclaimer: After you submit this questionnaire, a Patient Navigator will reach out to you within 72 hours to schedule an appointment for the Mobile Health Unit event you selected. Walk-ins are welcome, based on availability.
Please choose the event:*
You chose "Other", please specify:*
Are you a Rutgers student?*
- Yes
- No

What is your home campus?*
We just need to know a little more about you to get you in contact with our team:
Name*
First Last
Mobile Number:*
Alternate Phone Number:
Email:
Preferred communication method:*
- Text message
- Phone call
Can we leave you a voicemail?*
- Yes
- No
Age:*
Date of Birth:*
MM slash DD slash YYYY
Do you have a home address?*
- I do not have a home address
- I have a home address
Home address: *
Street Address:*
City:*
State:*
County:*
Zip Code:*
Gender identification:*
- Male
- Female
- Non-binary
Sex assigned at birth:*
- Male
- Female
Race/Ethnicity:*
Select all that apply
- American Indian/Alaska Native
- Asian
- Black/African American
- Caucasian/White
- Hispanic/Latino
- Native Hawaiian/Pacific Islander
- Southeast Asian
- Choose not to answer
Do you have health insurance?*
- Yes
- No
Which health insurance do you have?*
- Medicaid
- Medicare
- Private
- Other
You chose "Other", please specify:*
What is the name of your health insurance carrier?*

You’re almost done! Please answer the next few questions about your medical history:
Which screenings are you interested in?*
Select all that apply.
- Mammogram (breast cancer)
- Pap smear (cervical cancer)
- Colon cancer screening (FIT, colonoscopy, etc.)
- Prostate cancer screening (PSA, DRE)
- Skin cancer screening
- Lung cancer screening
- I’m not sure
Have you received any of the following screenings before?*
Select all that apply.
- Mammogram (breast cancer)
- Pap smear (cervical cancer)
- Colon cancer screening (FIT, colonoscopy, etc.)
- Prostate cancer screening (PSA, DRE)
- Skin cancer screening
- Lung cancer screening
- I’m not sure
Have you ever been diagnosed with cancer or received an abnormal screening result?*
- Yes
- No
- I don't know
When did you have this screening done?*
- Within the last 365 days
- 1 to 3 years ago
- 3 to 5 years ago
- 5 to 10 years ago
- I’m not sure
Do you need help with any of the following?*
Select all that apply
- Behavioral health services
- Care coordination (appointments, referrals, results, etc.)
- Communication support (forms, talking to doctors)
- Employment support
- Cultural or spiritual support
- Financial or insurance assistance
- Transportation assistance
- Food assistance
- Other
- I do not need support at this time
You chose "Other", please specify:*
How did you hear about us?*
- EPIC (MyChart message)
- Web Search
- Social Media (Instagram, Facebook, etc.)
- Community Event
- Word of Mouth
- Provider Referral
- Other
You chose "Other", please specify:*
Please describe the type of assistance you’re hoping to receive from the ScreenNJ team. This helps us better understand your needs before reaching out. Your responses are kept confidential and are not shared outside of ScreenNJ.

Consent Agreement*
As a part of the program, you will receive the following Patient Navigation Services:
- Connecting to health-related programs and services for patients/families and caregivers
- Assessing/resolving barriers and challenges
- Screening education and appointment arrangement
- Patient outreach and support
- Maintain follow-up communications with patients in need of additional assistance
In the event that I wish to withdraw my consent from Patient Navigation Services, I understand that I can text STOP to be removed from text-messaging. To no longer receive contact via phone, I have to contact my patient navigator with a written and verbal reason to discontinue services but will not be penalized and restricted from receiving or continuing medical services.

I understand that my personal information will remain confidential and in accordance with HIPPA as outlined on the patient log. I authorize freely and voluntarily and understand that I may refuse to sign it.
- I consent to the above services and terms and conditions.

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