2026 Online Colon Cancer Screening Kit

Free Colon Cancer Screening Kit

Omaha residents, ages 45 - 74 only
Name*

First NameLast Name
Date of Birth (You must be between the age of 45 - 74 to qualify for our program.)*

MonthDayYear
Date Kit Mailed Out

MonthDayYear
Date
Kit Number
Date Kit Received in Lab

MonthDayYear
Date
Lab Name
Kit Results
Date Results Letter/Email Sent

MonthDayYear
Date
Results sent to Primary Care Provider

YesNo, PC not providedSent patient info on colonoscopy if positive result
Gender*
Race*
Email*
We may email you to remind you to send in your kit, provide results, or see if you would like to participate in future years.
Address*

Street Address

Street Address Line 2

City - MUST BE Omaha Metro AreaState - MUST BE Nebraska

Zip Code
Phone Number*
We may send text reminders to return the screening kit.Format: (000) 000-0000.
How did you learn of the Free At-Home Colon Cancer Test Program?*

WorkplacePharmacySocial MediaRadioNews (Online or TV)Doctor's Office or ClinicCommunity EventChurchFamily Member or FriendColon Cancer Task Force WebsiteColon Cancer Task Force EmailOther
Please select which social media platform

FacebookInstagramTwitterOther
Please select which Pharmacy

WalgreensHyVeeBakersCVSOther
Please select your Workplace:

Mutual of OmahaMethodist Health SystemCHI HealthUnion PacificBlue Cross Blue Shield of NEOmaha Public SchoolsKiewitCharles SchwabOPPDNebraska MedicineNFMBorsheimsOther
Please select the Church location:

St. ColumbkilleBethel Missionary BaptistBeautiful Savior LutheranMt Sanai ChurchDundee PresbyterianFirst Covenant ChurchSt. Pius XSt. Wencelsalus + CamelotSt. John Vianney ResidenceGod's Missionary BaptistResurrection LutheranSt Paul Lutheran ChurchAntioch COGICSalem Baptist ChurchGretna Neighbors Food PantryNotre Dame Housing and Senior CenterChrist Child Center in Catholic Charities St Martin de Porres CenterOther
Please list the specific location or event of how you learned of our program:
Example: Family saw Facebook post
Name of your Primary Care Doctor
If you have a positive result, we will mail your doctor a letter notifying them.
Name of Primary Care Clinic
Address of Primary Care Clinic (cross streets are fine to list if you do not know exact address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Language*
Your Signature:
Should be Empty:

Free Colon Cancer Screening Kit