NJCEED Paterson City Residents Eligibility Screening

Thank you for taking the time to complete the NJ CEED screener survey. We appreciate your interest in taking part in our program.

Once completed, we will be in contact with you as soon as possible via telephone or email.

If you have any questions please feel free to email us at : njceed@hmhn.org

Are Paterson City Resident?

Es usted residente de la Ciudad de Paterson?

* must provide value

Yes

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Have you had a previous Diagnosis of Cancer?

Ha sido diagnosticado con Cancer previamente ?

* must provide value

Yes

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Do you have insurance (Including Medicaid,Charity Care )?
Tiene seguro medico ?

* must provide value

Yes

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Congratulations! You qualify to take part in the next part of the program. If you would like to participate, please click Yes to proceed with the program.
Felicitations! Usted califica para nuestro programa, si desea participar haga click en Si.

Yes

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Sorry, you are not currently eligible to take part in our program. However, if you are in need to cancer patient navigation services, please visit: https://screennj.org/
Disculpe, pero no califica para nuestro programa, si necsita ayuda para obtener servicios de prevencion para cancer visite :https://screennj.org/

Please enter your full name
Nombre y apellidos

* must provide value

Date of Birth:
Fecha de nacimiento:

M-D-Y

Home Address:
Direction :

City:
Ciudad:

State:
Estado:

Zipcode:
Codigo Postal:

Phone Number
Numero de Telefono:

* must provide value

Gender:
Genero:

Where did you hear about our program?
¿Dónde escuchaste de nuestro programa?

Other Needs?
Algo mas que te podriamos ayudar?

Based on your responses you are ineligible for this study.
Thank you for your time.

Basado en la informacion brindada, usted no es eligible para este programa.
Gracias por su tiempo!

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.