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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 you did not offer them a kit or they did not accept a kit.
For clients given a kit - after you have submitted the form electronically, print a copy of the PDF receipt provided and put it in the Home Test Kit for the client to complete Section B. The completed form should be posted 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. Access the Register and Privacy pages for more information.
If you have any questions about using this form please contact the National Cancer Screening Register on 1800 627 701.

Doctor/Medical Practice

Provide details of the Doctor/Medical Practice where a copy of the results of your test are to be sent.

Doctor details

Practice details

if they do the test a copy of their test result will be sent to this practice. if the Doctor details are not provided the test result will be sent to the principal GP at the practice.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 and telephone numbers will be updated on the Register with the information provided on the form; changing their name and address details in the National Bowel Cancer Screening Program will not change their Medicare details. To change Medicare details, please call 13 20 11.
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 defer (delay their kit) or opt out (be removed from the Program); and if they want to opt out now they can call the Program Information Line on 1800 118 868 or visit www.ncsr.gov.au.

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 can opt out (be removed from the Program). Opting out may be suitable for high risk individuals who have alternative monitoring arrangements for bowel cancer in place. You can submit an opt out form for your client at www.ncsr.gov.au. Inform the client that: if they do not complete the Opt-out 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 fill in an online form or call the Program Information Line if they wish to defer (delay their kit) or opt out (be removed from the Program); and if they want to opt out at any time they can call the Program Information Line on 1800 118 868 or fill in an online form at www.ncsr.gov.au.

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?

B3.

What is your Country of Origin?

B3.1

What is your preferred language spoken at home? (if known)

B3.2

Do you require Interpreter Services to understand English?

B4.

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
B5.

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
B6.

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

B7.

If you answered ‘Yes’ to questions B4, B5 or B6, what are your reasons for assistance?

Mark all applicable reasons
B8.

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

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
B9.

Your privacy

Your personal information is protected by law, including the Privacy Act 1988 (Cth) and the National Cancer Screening Register Act 2016, and is being collected for the Australian Government Department of Health, for the purpose of including information about you on the National Cancer Screening Register (NCSR) as part of the National Bowel Cancer Screening Program. Personal information about you has also been collected from the Department of Human Services as part of the process of inviting you to undergo screening and may be collected for follow-up after you have had a screening test.Your information may be used by the NCSR or given to other parties to provide you with healthcare, for the purpose of research, investigation or where it is required or authorised by law or court or tribunal order. If you require more information visit the website www.ncsr.gov.au.
B10.

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 out or defer 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 opt out or defer my participation in the Program at any time by completing the opt out or defer advice notice available on www.ncsr.gov.au or by phoning the National Cancer Screening Register Contact Centre on 1800 118 868 (free call); 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 60–85% 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 National Cancer Screening Register collecting sensitive information such as information about my health and racial or ethnic origin for the purpose indicated in Section B9 of this form. I also agree for my address to be updated as per the address provided in Section A of this form.If I have nominated a personal representative to act on my behalf in Section B8, I agree to the the NCSR contacting this person to confirm my nomination and if required to seek further legal documentation.
Date (dd/mm/yyyy)
_ _ /_ _ / _ _ _ _
B11.

My Health Record

My Health Record is an online summary of your key health information. For further information refer to www.myhealthrecord.gov.au. If you have a My Health Record, pathology reports may be uploaded to that record. You do not need to give consent every time but you need to indicate what tests you do not want uploaded to your record every time you have that test performed.When you do the National Bowel Cancer Screening Program test, your reports will be sent to My Health Record, unless you indicate you do not want this to happen by marking the box below.
B12.

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)