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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