Participant Information

Full Name: Date of Birth: ___________________ Age: _______ Phone Number: ______

Address: ________________________________City________State ____ZIP _________

Email (optional): __________________________________________

Preferred Method of Contact: ☐ Phone ☐ Text ☐ Email

Eligibility Screening

Please answer the following:

• Are you 45 years of age or older? ☐ Yes ☐ No

• Have you ever had a colonoscopy within the last 10 years? ☐ Yes ☐ No

• Have you completed a FIT (Fecal Immunochemical Test) within the last 1–3 years? ☐ Yes ☐ No

• Have you ever been diagnosed with colon cancer, colon polyps, inflammatory bowel disease (Crohn’s or ulcerative colitis), or a hereditary colon cancer syndrome (such as Lynch syndrome or FAP)? ☐ Yes ☐ No

• Do you currently have health insurance? ☐ No insurance ☐ Underinsured ☐ Insured

☐ I confirm that I am considered average risk for colorectal cancer and meet the eligibility criteria listed above.

About the Shield™ Cologuard® Test

The Shield™ Cologuard® test is a noninvasive stool-based screening test for colorectal cancer. It is intended for adults 45 years and older at average risk.

• The test detects DNA markers and blood in the stool that may be associated with colorectal cancer or advanced precancerous lesions.

• It is performed at home and does not require bowel preparation, sedation, or time off work.

• A kit will be provided with instructions for stool collection.

• The completed sample is mailed to the laboratory using prepaid packaging.

• Results are typically available within a few weeks.

Important:

• A positive result does not mean you have cancer, but it does require follow-up with a diagnostic colonoscopy.

• A negative result does not completely rule out cancer.

• This test is for screening only and is not appropriate for individuals at high risk.

Participant Acknowledgment

By signing below, I acknowledge:

• I understand the purpose of this screening test.

• I confirm that the information provided is accurate to the best of my knowledge.

• I understand that if my result is positive, I will need follow-up colonoscopy for further evaluation.

• I understand that participation in this outreach program is voluntary.

•  

Signature: _____________________________________________ Date: ______________

Office Use Only

 

Eligibility Confirmed: ☐ Yes ☐ No
Kit Provided: ☐ Yes ☐ No
Result Follow-Up Plan Documented: ☐ Yes ☐ No

Staff Initials: __________

 

 

What Is the Shield™ Test?

The Shield™ test is a blood-based screening test for colorectal (colon) cancer. It is designed for adults 45 years and older who are at average risk.

The test looks for circulating tumor DNA (ctDNA) in the blood that may be associated with colorectal cancer.

Who Should Use This Test?

This screening is appropriate for individuals who:

• Are 45 years or older

• Are at average risk for colon cancer

• Have not had a colonoscopy in the last 10 years

• Have not completed a FIT test in the last 1–3 years

• Have no insurance or are underinsured (for this outreach event)

This test is not recommended for individuals with:

• A personal history of colon cancer or colon polyps

• Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)

• A known hereditary colon cancer syndrome (such as Lynch syndrome or FAP)

How Is the Test Performed?

• A simple blood draw is performed.

• No bowel prep, stool collection, sedation, or diet changes are required.

• The blood sample is sent to a laboratory for analysis.

• Results are typically available within a few weeks.

Understanding Your Results

• Negative Result: No concerning cancer-associated DNA signals were detected. Continue routine screening as recommended.

• Positive Result: This does not mean you have cancer. It means a diagnostic colonoscopy is required to further evaluate the finding.

Why Screening Matters

Colorectal cancer often develops without symptoms in early stages. Screening helps detect cancer earlier, when it is more treatable.

Early detection saves lives.