CMF Field Screening Application - Sickle Cell Disease POC Testing

Field Screening Entrance

Verify your passcode and Unique Staff ID to begin collecting patient screening data.

Active CMF Screening Project

CMF National Sickle Cell Disease Screening Project

Location State: Lagos

Access Passcode *

Staff Unique ID No *

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Stage 1: Client Information

Is this a new client submission? *

Client Full Name (First & Last) *

Date of Birth *

Sex *

Phone Number

State of Residence *

Full Residential Address *

Comments (Stage 1)

Stage 2: Guardian Information

Guardian Full Name *

Relationship with Client *

Guardian Phone Number

Comments (Stage 2)

Stage 3: Consent Agreement

Consent Statement for Sickle Cell Disease Screening

I hereby consent to participate in the screening program for sickle cell disease organized by SALTED Health / Concerned Medics Foundation. I understand that the purpose of this screening is to identify individuals who may have sickle cell disease or carry the sickle cell trait.

I understand that participation in this screening services is voluntary, and I have the right to refuse to participate or withdraw from the screening at any time without penalty.

I have had the opportunity to ask questions and have received satisfactory answers. I understand the risks and benefits associated with participating in the screening service, and I consent to the collection and analysis of my blood sample for this purpose and the use of my data for future studies.

Does client consent to participating in screening service? *

Yes (Consent Granted)

No (Refused Consent)

Comments (Stage 3)

Stage 4: Sickle Cell Screening (Point of Care Testing)

Has client received blood transfusion in the last 3 months? *

No

Yes (Ineligible for POCT)

Has client been screened for Sickle Cell Disease using the POC system? *

Yes (Proceed to Results)

No (Unscreened)

Comments (Stage 4)

Stage 5: Results from SCD Screening

Screening Result *

Confirm Screening Result *

Take Photo of Results (Upload strip image for admin verification)

Has client received results of screening?

Has client received counseling about results?

Are results either Sickle Cell Anemia (Hb SS) or Sickle Cell Hemoglobin C Disease (Hb SC)? *

Comments (Stage 5)

Stage 6: Referral to Clinic

Optional Stage

Has client received clinic referral form?

Has client been linked to a treatment center?

Has client attended first clinic or has date set?

Date of First Clinic Day

Comments (Stage 6)

Stage 7: Patient Follow-Up Care

Optional Stage

Has the first follow-up been conducted?

Has client been linked to a support group?

Comments (Stage 7)

Stage 8: Annual Transcranial Doppler (TCD) Screening

Optional Stage

Has patient received the annual Transcranial Doppler screening?

Comments (Stage 8)