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Submission Received

Participant Details form (Health Service Initiated)
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What to do next

1.
2.
Print and give to the client
3.
They will need to complete Section B and post with the test kit.

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Participant Details form (Health Service Initiated)
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Participant Details form (Health Service Initiated)
Fields marked with  * are required

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Section A: Doctor/Medical Practice

Participant Details form (Health Service Initiated)
Fields marked with  * are required
Please note: Complete and submit this form to the Register for all clients assessed for bowel screening even if unsuitable for screening (you did not offer them a kit) or they did not accept a kit.
For clients given a kit - print a copy of this form after you have submitted it and put the form in the Home Test Kit for the client to complete and post to the lab with their completed samples.
You must seek consent from all clients for the information on this form to be submitted to the Register and the Program’s Pathology Provider and inform the client that the information may be used to provide them with screening reminders, future invitations, results and follow up, as well as to monitor and evaluate the Program. Note: If a person is aged between 50 and 74, and is registered with Medicare or the Department of Veterans’ Affairs, their information will already be on the Register. Click here to find out more about the Register and Privacy.

Doctor/Medical Practice

Details of the Doctor/Medical Practice where bowel screening test results to be sent.

Doctor details

Practice details

if they do the test a copy of their test result will be sent to this practice; and. this practice may be contacted by the Program Register to discuss their screening invitation, results and follow-up.

Client name and contact details

Date of birth
Date of birth *
Gender
Contact telephone numbers
Contact telephone numbers * (Please provide at least one phone number)

Declaration

their address will be updated when the form is returned to the program with the test samples; their address and telephone numbers will be updated on their Medicare record with the information provided on the form;the address will also be updated for all other people on the same Medicare card; andif the client is listed on a Medicare card with others and they do not want the address change applied to everyone on their card, they will need to contact Medicare to transfer to a new card.
Note: the accuracy of the name, Date of Birth and Medicare No. is essential to assist in identifying the client on Medicare records and the Program Register.

Bowel Screening Assessment Outcome

Participant Details form (Health Service Initiated)
Fields marked with  * are required

Bowel Screening Assessment Outcome

Complete this section for all clients assessed - select one option only. For information on assessing suitability refer to the Checklist for talking to your patient about doing a bowel screening test.

Client suitable for screening and provided with kit

Client suitable for screening but declined kit.

Select the reason from the list below:
Inform the client that: they will be invited by mail at their next eligible age - this date can be checked at www.cancerscreening.gov.au/eligibility; 4-6 weeks before a kit is sent they will receive a ‘pre-invitation letter’ which will inform them to call the Program Information Line if they wish to suspend (delay their kit) or opt off (be removed from the Program); and if they want to opt off now they can call the Program Information Line on 1800 118 868.

Client assessed as not suitable for screening at this point and not provided with kit

Select the reason from the list below:
Clients who are not suitable for screening may elect to opt off (be removed from the Program). Opting off may be suitable for high risk individuals who have alternative monitoring arrangements for bowel cancer in place. These clients should be provided the Opt-Off (Health Service Initiated) form to complete and mail to the Register. Inform the client that: if they do not complete the Opt-off form they will be invited by mail at their next eligible age - this date can be checked at www.cancerscreening.gov.au/eligibility; 4-6 weeks before a kit is sent they will receive a ‘pre-invitation letter’ which will inform them to call the Program Information Line if they wish to suspend (delay their kit) or opt off (be removed from the Program); and if they want to opt off now they can call the Program Information Line on 1800 118 868.

Section B: For completion by the client to send back with their samples

Participant Details form (Health Service Initiated)
Fields marked with  * are required
Please use a black pen and write in BLOCK LETTERS in the boxes provided.
B1.

Test sample details - Please record the dates you take your samples

B2.

Are you of Aboriginal and Torres Strait Islander origin?

If you are of both Aboriginal and Torres Strait Islander origin, please tick both boxes
B3.

Do you ever need someone to help you with, or be with you for, self care activities?

For example, doing everyday activities such as eating, showering or dressing
B4.

Do you ever need someone to help you with, or be with you, for body movement activities?

For example, getting out of bed, moving around at home or at places away from home
B5.

Do you ever need someone to help you with, or be with you, for communication activities?

B6.

If you answered ‘Yes’ to questions B3, B4 or B5, what are your reasons for assistance?

Mark all applicable reasons
B7.

Please complete this section if you would like to authorise another person to talk to the staff of the National Bowel Cancer Screening Program for you.

This does not authorise the nominated person to change your contact details.
If you wish to update these details at any time, please call the Program Information Line on 1800 118 868.
Their relationship to you
B8.

Your privacy

Your personal information is protected by law, including the Privacy Act 1988, and is being collected by the Australian Government Department of Human Services for the purposes of including information about you on the National Bowel Cancer Screening Register as part of the National Bowel Cancer Screening Program. Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. You can get more information about the way in which your personal information will be managed at www.cancerscreening.gov.au/nbcsp-privacy or www.humanservices.gov.au/privacy. Samples that are posted to the Program laboratory are analysed on the same day they are received. After analysis, the sample tubes are kept in a secure room for seven days and then placed into a secure bin for destruction. By participating in this Program you consent to your information being collected for this purpose.
B9.

Acknowledgement

I acknowledge that:by completing and returning this form and/or the test to the pathology laboratory I am agreeing to become a participant in the National Bowel Cancer Screening Program; by agreeing to participate in the National Bowel Cancer Screening Program I agree to being invited again in the future to complete tests during the period I am eligible to participate except during any time I opt off or suspend my participation; the Doctor/Medical Practice listed in Section A of this form will be sent a copy of my test result and that I can call the National Bowel Cancer Screening Program Information Line on 1800 118 868 (freecall) if I want to change this to a different Doctor/Medical Practice; I may suspend my participation or opt off the Program at any time by completing the reply paid opt off/suspend advice notice included in the Information Booklet or by phoning the National Bowel Cancer Screening Program Information Line on 1800 118 868 (freecall); I have read, or had explained to me, and understand the National Bowel Cancer Screening Program Information Booklet, the Your Privacy section of this form and the test instructions; and the test samples I have provided will be tested for the presence of blood, and I understand that: screening tests are not always 100% accurate and therefore test results cannot be guaranteed (studies indicate that these tests detect 70–80% of cancers); and if blood is found in the sample provided it is my responsibility to contact a doctor to discuss the results, the nature and risks of any further tests and to arrange for further tests following a full clinical assessment. It is not the responsibility of the Program or its employees, agents or anyone connected with this test procedure to do this for me.ANDI consent to the Department of Human Services collecting sensitive information such as information about my health and racial or ethnic origin for the purpose indicated in Section B8 of this form. I also agree for my address to be updated as per the address provided in Section A of this form.
Date (dd/mm/yyyy)
_ _ /_ _ / _ _ _ _
B10.

Return this form with your test samples in the reply paid envelope provided.

If you have already sent the test samples but did not include this form, send it to:
The National Bowel Cancer Screening Program (NBCSP)