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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 quick 10 questions about your medical history:
Do you currently smoke tobacco or have you smoked tobacco in the past?*
- I have never smoked
- I currently smoke
- I previously smoked
How many years ago did you quit?*
For how many years did you smoke?*
How many packs a day do you smoke?*
How many packs a day did you smoke?*
Do you have a family history of cancer?*
- Yes
- No
- Unknown
Have you ever had a mammogram?*
- Yes
- No
- Not applicable
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
Have you ever had a pap smear?*
- Yes
- No
- Not applicable
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
Have you ever received a screening for colon cancer?*
Example: Colonoscopy- An exam that uses a special tool to check your colon and rectum. This is often done while you are asleep, but you can choose to be awake for the exam. Or FIT which is when a flat stick is used to place samples of stool on a special card and returned to a doctor or laboratory for testing.
- Yes
- No
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
Have you ever received a screening for prostate cancer?*
(Note: This question is for males only) Example: PSA, DRE
- Yes
- No
- Not applicable
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
Have you noticed changes in your skin?*
Example: Mole changes
- Yes
- No
Do you use sunscreen when outdoors?*
- Yes
- Sometimes
- No
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 additional support in any of the following areas?*
Care Coordination, Communication, Employment, Cultural and Spiritual, Financial and Insurance, Transportation Services, Behavioral Health Services
- Yes
- No
What type of support do you need?*
Please check all that apply
- Care Coordination (i.e.: appointments, referrals, retrieval of diagnostic imaging results)
- Communication (i.e.: understanding documents, talking to doctors)
- Employment (i.e.: finding a job, working while receiving treatment)
- Cultural and Spiritual (i.e.: difficulty coping, beliefs, existing health condition)
- Financial and insurance (i.e.: difficulty paying medical bills, no insurance, or insurance does not cover costs)
- Other
- Behavior Health Services
You chose "Other", please specify*
Do you need help with transportation services?*
- Yes
- No
Do you need help with food security?*
- Yes
- No
How did you hear about us?*
- Brochure or poster
- Community event
- Mobile health unit (van offering free screenings)
- Social Media

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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Continued use of this site signifies your consent and agreement with these Terms and Conditions.

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