Community FIT Kit Request Form for Men & Women 45-74

IF YOU ARE FROM the following counties, click on link below to the right of counties listed to be redirected to their county health department FIT Kit Request Form:

DODGE, SAUNDERS, WASHINGTON	Three Rivers District Health Department
MADISON, STANTON, CUMING, BURT	Elkhorn Logan Valley Public Health Department
LANCASTER	Lancaster County Health Department
ADAMS, CLAY, WEBSTER, NUCKOLLS	South Heartland District Health Department
BOX BUTTE, SIOUX, DAWES, SHERIDAN, BANNER, KIMBALL, MORRILL, CHEYENNE, GARDEN, DEUEL, GRANT, SCOTTS BLUFF	Panhandle Public Health District

If you are from any other county, please continue below.

ALL QUESTIONS MUST BE ANSWERED. Please print clearly.
Read and sign.
Submit the completed form. Once we review your form a FIT Kit will be mailed to you with instructions for completing and returning the kit.

To change language, click on current language in upper right to bring up language options, then select desired language.

FOR INTERNAL USE ONLY:

Click on "Processed" checkbox once enrollment has been processed.

Processed

First Name
Middle Initial
Last Name
Maiden Name (optional)

Birthdate

Participant Age:

* must provide value

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You ARE NOT eligible to request a FIT Kit as you are under age 45 or over age 74.

Please correct birth date or if age is correct, please click on "Yes". By clicking "Yes", this will end your online FIT Kit form as you are not eligible for these benefit(s).

Address

Best Phone Number to Reach You

City:

* must provide value

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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.