The code block below illustrates how one might use # and // as comments in your logic and calculations.
# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,
// This comment can explain what the next line does.
[score] * [factor],
// Return '0' if the condition is False.
0
)
Working...
0% means
50% means
100% means
This value you provided is not a number. Please try again.
This value you provided is not an integer. Please try again.
The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.
The value you provided must be within the suggested range
The value you provided is outside the suggested range
This value is admissible, but you may wish to double check it.
The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).
This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.
This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.
This field must be a valid email address (like joe@user.com). Please re-enter it now.
The value you provided could not be validated because it does not follow the expected format. Please try again.
Required format:
5juvdgy2bLRcMUxgsTJdQGSexAq
Utah Breast and Cervical Cancer Screening Program Enrollment Form
If you have already completed part of the survey, you may continue where you left off. All you need is the return code given to you previously. Click the link below to begin entering your return code and continue the survey.
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NOTE: This form is also available in Spanish. To switch languages, select the "English" button located in the upper-right corner of the form.
The Breast and Cervical Cancer screening program is provided by the Utah Department of Health and Human Services and paid for with state and federal funding. We collect some personal and medical information from you and your medical providers when you agree to participate in the program.
Federal and state laws protect the information we collect, create, or keep about you. Your information will be kept secure. We will not give it to others without your consent, or as allowed or required by law. You don't have to give us any information. However, you may not be able to get services from the program if we don't have enough information to see if you qualify.
How will you use my information?
To find out if you qualify for the program.
Help you get screening and diagnostic follow-up services.
Help connect you to resources to support your treatment (if needed).
Remind you about upcoming screenings and tell you about other program opportunities.
Send you reminders by text, email, or mail.
Manage and evaluate the program.
What type of information will you collect about me?
You give permission for your doctors and other participating service providers to give us the following information when you sign up for the program:
Personal information (including your name, date of birth, address, and phone number).
Contact information for your doctors and other health care providers.
Medical information collected while you participate in the program.
Information related to the cost of procedures and services.
You also give us permission to share information we have about you with healthcare providers and doctors involved in your medical care and with the Utah Cancer Registry.
You give us permission to share this information to the Department of Workforce Services if you need more additional coverage for treatment.
Can I cancel my permission?
Yes. You can leave the program at any time. You must send a letter to the Breast & Cervical Cancer Screening Program to cancel your permission. The letter must include:
The date
Your name
Your date of birth
A statement in writing that says you want to cancel your permission to release your information
Your signature
Important information:
You will no longer be enrolled in the program if you cancel your permission. This means you may have to pay for any outstanding medical costs for any services you got while you were in the program- if you cancel your permission before everything is paid.
Send a letter to cancel permission to:
You have selected an option that triggers this survey to end right now.
To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.
