STATE OF MARYLAND
STATE OF MARYLAND
DHMH
Maryland Department of Health and Mental Hygiene
201 W. Preston Street • Baltimore, Maryland 21201
Martin O’Malley, Governor – Anthony G. Brown, Lt. Governor – John M. Colmers, Secretary
Family Health Administration
Russell W. Moy, M.D., M.P.H., Director – Donna Gugel, Deputy Director
CCSC HO #11-01
MEMORANDUM
Date: January 7, 2011
To: Health Officers
CRF-CPEST Cancer Coordinators
SAHC CRF Coordinators
From: Carmela Groves, Program Manager, Surveillance and Evaluation Unit, CCSC
Re: Revised CDB Forms: Core Demographics and Colorectal Cancer Screening,
CDB Guidance #54
We revised two Client Database (CDB) forms: Core Demographics Form and Colorectal Cancer (CRC) Screening Form. The forms, dated 01/04/2011, are attached for your immediate use in PDF and in Word; please discard the old versions of these forms.
The main changes to the forms are:
Core Demographics Form (DHMH 4625 Rev. 01/04/2011)
Page 1: Added ‘Internet’ as an option for the ‘Learn of Program’ field
Page 2: Added ‘PAC’ as an option for the fields ‘type of primary health insurance’ and ‘type of secondary health insurance,’ if covered by health insurance
Colorectal Cancer (CRC) Screening Form (DHMH 4627 Rev. 01/04/2011)
Pages 2, 3, 4: Changed “DCBE” to “Imaging” (this includes double contrast barium enema (DCBE), single contrast barium enema (SCBE), Virtual Colonoscopy or CT colonography, or other imaging study)
The CDB data entry screens are being modified to reflect these changes. Please contact me if you have any questions (cgroves@dhmh.state.md.us, 410-767-2616). Thank you.
cc: Russell Moy, M.D., M.P.H.
Donna Gugel, M.H.S.
Kelly Sage, M.S.
Diane Dwyer, M.D.
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