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Program Manual
Breast and Cervical Cancer Control Program
NC BCCCP Manual, Edition 17, January 2023
000 - Memo
Rev. 1/23
001 - ProgramManual Cover
Rev. 1/23
002 - Table of Contents
Rev. 1/23
100 - BCCCP Overview Divider
101 – NC BCCCP Overview Handout - Updated 2/2023
102 – Sample BCCCP Agreement Addendum - Updated 2/2023
103 Sample SoW
104 - BCCCP Screening and Follow-Up Protocol - Updated 6/22
105 - Navigator Responsibilities - Updated 6/22
106 - NC BCCCP ACA
-
Updated 1/24
107 - NC BCCCP Cervical Screening Policy
108 - NC BCCCP Colorectal Cancer Screening Policy
-
Updated 1/24
109 - NC BCCCP Diagnostic Cap Policy
-
Updated 1/24
110 – NC BCCCP Family Planning Patient Policy
-
Updated 1/24
111 - Patient Navigation Policy
112 - NC BCCCP Risk Assessment Policy - Updated 6/22
200 - Eligibility Divider
201 – Federal Poverty Guidelines – Updated 01/24
202 – Sliding Fee Schedule – Updated 01/24
203 - BCCCP Eligibility FAQ – Updated 11/22
204 - Breast Eligibility Flow Chart – Updated 11/22
205 - Cervical Eligibility Flow Chart – Updated 11/22
300 - Budget Divider
301 - Budget PowerPoint© Handout
302 - NC BCCCP Services Fee Schedule
-
Revised 1/10/2024
303 - Local Health Department Monthly Expenditure Report
304 - Contract Expenditure Report Template
305 - Contract Expenditure Report Tracking Log
306 - Agency Action Plan Template
400 - Patient Navigation Divider
401 - Patient Navigation Kit June 2023
Updated 6/23
402 – Patient Navigation Appendix Divider
-
New 3/23
402A – Patient Navigation Process Algorithm
-
Updated 4/23
402B – Patient Navigation Needs Assessment & Care Plan
-
Updated 3/23
402C – Patient Navigation Only for BCCM Application Process
-
Updated 4/19
402D – Patient Navigation Only Data Reporting Form
-
Updated 3/23
500 - Quality Assurance Divider
501 – Monitoring Visit Process
Updated 11/22
502 – Provider Performance Monitoring & Evaluation
Updated 8/22
503 - Pre-Assessment Survey
Updated 3/23
504 - Triennial Program Review
Updated 3/23
505 – BCCCP Clinical Record Review Form
Updated 4/23
506 - Corrective Action Plan Template
Updated 3/23
507 – Most Common Reasons for Corrective Actions
Updated 11/22
508 – Quality Improvement Recommendations Template
Updated 3/23
600 - Data Entry Divider
601 - Data Entry PowerPoint Handouts
602 - Data Training Mapping Guide
603 - BCCCP Codes for the Comment Field
604 - BCCCP Error Messages
605 - BCCCP Timeliness and Adequacy of follow up Algorithms
606 - Provider Codes
700 - Recruitment & Marketing Divider
701 – Recruitment & Outreach Presentation Handout
Updated 7/22
702 - Recruitment Reporting Form
703 - NC BCCCP Services Brochure
704-NC BCCCP Do You Need Breast Cancer Screening – English – Updated 01/22
705 NC BCCCP Do You Need Breast Cancer Screening – Spanish – New 01/22
706 – NC BCCCP Do You Need Cervical Cancer Screening – English – Updated 01/22
707 – NC BCCCP Do You Need Cervical Cancer Screening – Spanish – New 01/22
708 – Materials Order Form
New - 2/2024
800 - Professional Development Divider
801 - Professional Education Websites
802 - NC BCCCP-WISEWOMAN ERRN Protocol Policy
Added 5/23
803 - PAA STD Challenge Application
Added 5/23
804 - NC BCCCP ERRN Re-Rostering Requirements
Added 5/23
805 - NC BCCCP ERRN Clinical Skills Assessment Tool
Added 5/23
806 - PAA ERRN Challenge Guidelines
Added 5/23
807 - Sample Standing Order - Breast Cancer Screening
Added 5/23
808 - Sample Standing Order - Cervical Cancer Screening
Added 5/23
809 - Sample Standing Order - Laboratory Test Cervical Cancer Screening
Added 5/23
900 - BCCM Divider
901 - BCCM Presentation Handout
902 - BCCM Flyer
Rev. 7/22
903 - Additional BCCM Information
Rev. 10/22
904 - DMA-5087 Checklist
905 - DHB-5087-SP
906 - DHB-5079
907 - DHB-5079-SP
908 - DMA-5081
909 - DHB-5081-ia-SP
910 - BCCM Recertification (DHB-5081-R) - English
Rev. 3/21
911 - BCCM Recertification (DHB-5081-R) - Spanish
Rev. 3/21
912 - Non BCCCP Funding Sources
Rev. 4/23
913 - NCONA 2021 Resource Guide
914 Komen Treatment Assistance Flyer - English
915 Komen Treatment Assistance Flyer - Spanish
916 Komen Breast Cancer Helpline - English
917 Komen Breast Cancer Helpline - Spanish
1000 - Forms Divider
1001 - Staff Change Notification Form
Rev. 4/23
1002 - BCCCP Consent English
1003 - BCCCP Consent Spanish
1004 - Sample History and Physical Form
Rev. 5/23
1005 - Sample Physician Letter Regarding Covered Payment for Services
Rev. 12/22
1006 - Data Entry Coding Sheet - Breast Cancer Screening
Rev. 2/23
1007 - Data Entry Coding Sheet - Cervical Cancer Screening
Rev. 2/23
1008 - Patient Navigation Only Data Collection Form
1009 - QuitlineNC Information
Rev. 2/23
1010 - QuitlineNC eReferral Portal Guide
Added 5/23
1011 Declination Form English
1012 Declination Form Spanish
1100 - Comprehensive Cancer Control Program Divider
1101 - NC Comp Cancer Presentation Handout
1102 - NC Comp Cancer Overview.pdf
1103 - Breast Cancer Fact Sheet 2021 NC CCCP
1104 - Cervical Cancer Fact Sheet 2021 NC CCCP
1105 ExpandYourHorizons Partner Guide NC CCCP
1106 – NC CCCP Resource Toolkit Order Form
1200 - NC WISEWOMAN Program Divider
1201 – NC WISEWOMAN Program Summary - Updated 1/5/2023
1202 - NC WISEWOMAN Postcard
1300 - Cancer Branch Staff Divider
02/09/2023
1301 - Nurse Consultant Map
01/04/2023
1302 - CB Staff Roster
03/12/2024
