Welcome to the TCO Data Portal. Please enter any data available for this participant. To save your responses and return at a later date, please click " Save & Return Later" to generate a Return Code specific to this participant. Please document this Return Code as you will need it to access the participant's record again. When you are ready to resume entering data, use the " Returning?" button at the top right of the TCO Data Portal landing page.
IMPORTANT:
ALL FIELDS ARE REQUIRED. When you are finished with all of the data entry for a TCO participant, click Submit. A pop-up window will display any missing data, which you will be required to enter before submitting. See the TCO website (program manual or the Direct Assistance Worksheet) for required data points.
THE PARTICIPANT MUST RECEIVE A WRITTEN TCO DATA COLLECTION NOTIFICATION before data can be entered into this portal. CDPHE cannot collect information for individuals who have not received this notification. Save time by not attempting to enter data for these participants.
If you have any questions, please email Alice Choi (alice.choi@state.co.us ). She will be happy to help you with anything you may need.
Please select your organization from this dropdown list
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Tepeyac Community Health Center Denver Health and Hospital Authority Heart of the Rockies Regional Medical Center (HRRMC) Foundation High Plains Community Health Center Inner City Health Center Montrose Memorial Hospital Penrose St. Francis Hospital San Juan Basin Public Health Somali American Community Center of Colorado Southern Ute Indian Tribe Spanish Peaks Outreach and Women's Clinic Trailhead (Vuela for Health) Uncompahgre Medical Center Ute Mountain Ute Tribe Weld County Department of Public Health ViVe Wellness 365 Health Summit Community Care Clinic North Colorado Health Alliance Colorado Council of Black Nurses
Please select a response:
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I confirm that this TCO participant received a written TCO Data Collection Notification.
This TCO participant was not provided a written TCO Data Collection Notification or objected to sharing data. I understand that I cannot enter data into this portal for this participant and the survey will end.
Enter the name of outreach staff providing direct assistance
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TCO Participant's InitialsEntered as "XY" where X is the participant's first initial and Y is the participant's last initial. Do not include quotation marks.
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Can you provide an eCaST Client ID for this TCO participant?
If the participant is likely to be eligibile for CPED HNCS strategy but does not yet have an eCaST Client ID, please click "Yes" and leave the eCaST ID field blank until an eCaST Client ID number is available.
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Yes, I can provide an eCaST Client ID for this TCO participant
No, I cannot provide an eCaST Client ID. Please assign a TCO ID for this TCO participant.
Enter eCaST Client ID for this TCO Participant
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View equation Has a TCO Participant ID already been issued for this participant (e.g., have you assisted the participant previously)?
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Yes - Please contact the TCO Data Manager to reopen an existing record.
No
This is TCO Participant's TCO ID.
Document this number in your organization's TCO participant record.
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This TCO Participant's TCO ID is: ______
Did you document the TCO ID Number presented above in your records for this TCO Participant?
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Yes
Date participant first contacted by outreach worker. Enter as MM-DD-YYYY
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Today M-D-Y
Date participant last contacted by outreach worker.Enter as MM-DD-YYYY
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Today M-D-Y
Total number of contacts
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How was the participant first identified as a potential candidate for direct assistance?Select one
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Outreach worker identified participant in the community
Outreach worker identified participant through existing organizational records
Outreach worker was given participant information
Participant contacted outreach worker
Outreach worker identified participant in the community at...Select one
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Church/faith center
Class (e.g., Charlar, Cooking Matters, etc.) Hosted by: ____________________
Community/recreation/senior center (not tribal center)
Corrections facility
Cultural or community event e.g., cultural fair, holiday party, career fair)
Food bank/pantry (not grocery store/farmer's market)
Government/immigration office (e.g., consulate, etc. but not social services)
Grocery store/farmer's market (not food bank/pantry)
Health-focused fair or event (e.g., health fair, 5K, lunch-and-learn, etc.)
Health clinic (e.g., walk-in patient, or patient for other health services)
Homeless services (shelter, meals, etc., but not social services)
Mental health or addiction services (e.g., mental health center, behavioral health group/class, AA meeting, rehab, transitional home/halfway house, etc.)
Restaurant
School/learning center (e.g., preK-12, colleges, technical schools, etc.)
Social/human services (e.g., government assistance for food/housing, etc.)
Tribal center/complex
Other
You chose "Other" as the point of first contact, please tell us where in the community you first contacted the participant
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Outreach worker identified participant through existing organizational records...Select one
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EHR/EMR, including custom registries
Registry
Mailing list, list of previous clinical clients or organization participants
Other
You chose "Other" as the type of record, please tell us what type of record identified the participant
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Outreach worker was given participant information by...Select one
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Someone in my organization (e.g., medical provider, other department)
Someone from another organization
Other
You chose "Other" as the source of participant information, please tell us where first contact was made.
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Participant contacted outreach worker as a result of...Select one
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Flyer, poster, brochure, other printed material distributed in community
Non-personalized postcard or other mailer (e.g., zip code mailings)
Social media (Facebook, Twitter, Instagram, etc.)
Organization website or listing on a website
Friend or family member (not outreach worker) referred to program
If you have more details about how this participant was contacted, please provide them here. OPTIONAL
Select all screening types for which you are reporting participant demographic data. You can return at any time to add additional screening types.
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County of residence:
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Adams Alamosa Arapahoe Archuleta Baca Bent Boulder Broomfield Chaffee Cheyenne Clear Creek Conejos Costilla Crowley Custer Delta Denver Dolores Douglas Eagle El Paso Elbert Fremont Garfield Gilpin Grand Gunnison Hinsdale Huerfano Jackson Jefferson Kiowa Kit Carson La Plata Lake Larimer Las Animas Lincoln Logan Mesa Mineral Moffat Montezuma Montrose Morgan Otero Ouray Park Phillips Pitkin Prowers Pueblo Rio Blanco Rio Grande Routt Saguache San Juan San Miguel Sedgwick Summit Teller Washington Weld Yuma Outside of Colorado Unknown
Gross monthly household income (before taxes):
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Number of people living on this income including participant (this may include people not living at the same house):
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Ethnic Identity
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Neither Hispanic or Latina
Hispanic and/or Latina
TCO participant not sure
TCO participant was not asked
TCO participant refused to answer
Unknown or unable to determine
The option "
Racial Identity
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Tribal Affiliation:If this is unknown, please type "unknown" into the box.
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Please specify "Other" selection above:If this is unknown, please type "unknown" into the box.
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The option "
Insurance status:
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The option "
Select all limitations to participant's private insurance
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Medicare type:
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Part A Only
Both Part A and Part B
Unknown
Education
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< 9 grade
Some high school
High school graduate or equivalent
Some college or higher
Unknown or unable to determine
Does participant smoke tobacco?Includes cigarettes, pipes or cigars (smoked tobacco in any form), but does not include tobacco used for ceremonial or traditional purposes.
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Current smoker
Quit
Never smoked
Unknown or unable to determine
Does this TCO participant smoke commercial tobacco?
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Yes
No
Unknown
Prior to receiving direct assistance, did the participant have a place where they regularly went for routine health care (other than hospital emergency room or urgent care)?
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Yes
No
Unknown or unable to determine
Has this participant ever been waitlisted before receiving direct assistance?
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Yes
No
Unknown or unable to determine
Cancer Screening History & CPED Eligibility Has participant ever had a mammogram?
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Yes
No
Unknown or unable to determine
Within the last 2 years
More than 2 years ago
Never
Unknown
Has participant ever had a Pap and/or HPV test?
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Yes
No
Unknown or unable to determine
Within the last 3 years
More than 3 years ago
Never
Unknown
Within the last 5 years
More than 5 years ago
Never
Unknown
Is participant eligible for cancer screenings paid with funds from CPED's HNCS strategy for uninsured clients?
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Yes
No
Unknown or unable to determine
Cardiovascular Screening History Last Blood Pressure (BP) check
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Within the last 1 year
More than 1 year ago
Never
Unknown
Within the last 5 years
More than 5 years ago
Never
Unknown
Within the last 1 year
More than 1 year ago
Never
Unknown
The option "
Self-reported issues/concerns/symptoms:
The option "
Select all screening types for which this participant had identified barriers. You can return at any time to add additional screening types.
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You indicated that this participant experienced no barriers to accessing a screening. If this is incorrect, please return to the previous question and select the screening types for which this participant had barriers identified or close this survey and return once a barrier assessment has been completed. If barriers were not assessed for this participant, then direct assistance is not needed and data should not be reported for this participant. Check the box to the right to end this survey and delete this record.
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I affirm that this participant had no barriers to screening and will not be included in the TCO data.
Select ALL identified barriers to breast cancer screening .
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Cultural Beliefs/Behaviors: Cultural barriers may include cultural or religious beliefs or behaviors related to health or health practitioners.
Disability/Mobility Issues: Mobility barriers may include functional issues, such as disability; ADL assistance needed; mobility issues such as needing a cane, walker, wheeler; recent fall/falls; etc.
Financial Assistance Needed: Financial barriers may include the need for clothing, food, utilities or rent/mortgage assistance or having a fixed, low or no income, no job, etc.
Health Literacy: Health literacy barriers may include a lack of cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.
Homelessness or Inadequate Housing: Housing barriers may include needs related to shelter, unsafe housing, utility problems, etc.
Insurance: Insurance barriers may include insurance literacy (e.g., lack of understanding about what coverage entails or requires/never had insurance, including Medicaid), high deductible, no insurance, underinsured, or insurance does not cover services/equipment.
Language: Language barriers may include language differences from health provider (e.g., not confident speaking in English), unable to read, etc.
No Dependent Care (Child): Dependent care barriers (for children) may include children who are disabled, have full-time care needs, or other issues caring for dependent children as identified by the community member.
No Dependent Care (Adult): Dependent care barriers (for adults) may include a dependent with Alzheimer's or who is disabled, has full-time care needs, or other issues caring for dependent adults as identified by the community member.
Psycho-Social Issues: Psycho-social barriers may include alcohol abuse, anxiety, depression, drug abuse, fear, peer/family pressure, poor coping skills, etc.
Support Minimal: Support barriers may include a lack of caregiver support, difficulty coping/emotional, minimal or no family support, no spiritual support, unsafe family, etc.
Transportation: Transportation barriers may include limited vehicle access, medical transport required, no driver's license, no gas money, unable to drive due to illness, etc.
Work: Work barriers may include fear of losing a job, FMLA, lost job due to illness, no sick time, physically unable to work, etc.
Other: Other barriers could include: health management needs, in-home care needs, a lack of awareness or knowledge about legal status or rights, lack of access to prescriptions or supplies, or other barriers identified by the community member.
Describe other barrier(s) to breast cancer screening .
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Select ALL identified barriers to cervical cancer screening .
* must provide value
Cultural Beliefs/Behaviors: Cultural barriers may include cultural or religious beliefs or behaviors related to health or health practitioners.
Disability/Mobility Issues: Mobility barriers may include functional issues, such as disability; ADL assistance needed; mobility issues such as needing a cane, walker, wheeler; recent fall/falls; etc.
Financial Assistance Needed: Financial barriers may include the need for clothing, food, utilities or rent/mortgage assistance or having a fixed, low or no income, no job, etc.
Health Literacy: Health literacy barriers may include a lack of cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.
Homelessness or Inadequate Housing: Housing barriers may include needs related to shelter, unsafe housing, utility problems, etc.
Insurance: Insurance barriers may include insurance literacy (e.g., lack of understanding about what coverage entails or requires/never had insurance, including Medicaid), high deductible, no insurance, underinsured, or insurance does not cover services/equipment.
Language: Language barriers may include language differences from health provider (e.g., not confident speaking in English), unable to read etc.
No Dependent Care (Child): Dependent care barriers (for children) may include children who are disabled, have full-time care needs, or other issues caring for dependent children as identified by the community member.
No Dependent Care (Adult): Dependent care barriers (for adults) may include a dependent with Alzheimer's or who is disabled, has full-time care needs, or other issues caring for dependent adults as identified by the community member.
Psycho-Social Issues: Psycho-social barriers may include alcohol abuse, anxiety, depression, drug abuse, fear, peer/family pressure, poor coping skills, etc.
Support Minimal: Support barriers may include a lack of caregiver support, difficulty coping/emotional, minimal or no family support, no spiritual support, unsafe family, etc.
Transportation: Transportation barriers may include limited vehicle access, medical transport required, no driver's license, no gas money, unable to drive due to illness, etc.
Work: Work barriers may include fear of losing a job, FMLA, lost job due to illness, no sick time, physically unable to work, etc.
Other: Other barriers could include: health management needs, in-home care needs, a lack of awareness or knowledge about legal status or rights, lack of access to prescriptions or supplies, or other barriers identified by the community member.
Describe other barrier(s) to cervical cancer screening .
* must provide value
Select ALL identified barriers to cardiovascular screening.
* must provide value
Cultural Beliefs/Behaviors: Cultural barriers may include cultural or religious beliefs or behaviors related to health or health practitioners.
Disability/Mobility Issues: Mobility barriers may include functional issues, such as disability; ADL assistance needed; mobility issues such as needing a cane, walker, wheeler; recent fall/falls; etc.
Financial Assistance Needed: Financial barriers may include the need for clothing, food, utilities or rent/mortgage assistance or having a fixed, low or no income, no job, etc.
Health Literacy: Health literacy barriers may include a lack of cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.
Homelessness or Inadequate Housing: Housing barriers may include needs related to shelter, unsafe housing, utility problems, etc.
Insurance: Insurance barriers may include insurance literacy (e.g., lack of understanding about what coverage entails or requires/never had insurance, including Medicaid), high deductible, no insurance, underinsured, or insurance does not cover services/equipment.
Language: Language barriers may include language differences from health provider (e.g., not confident speaking in English), unable to read, etc.
No Dependent Care (Child): Dependent care barriers (for children) may include children who are disabled, have full-time care needs, or other issues caring for dependent children as identified by the community member.
No Dependent Care (Adult): Dependent care barriers (for adults) may include a dependent with Alzheimer's or who is disabled, has full-time care needs, or other issues caring for dependent adults as identified by the community member.
Psycho-Social Issues: Psycho-social barriers may include alcohol abuse, anxiety, depression, drug abuse, fear, peer/family pressure, poor coping skills, etc.
Support Minimal: Support barriers may include a lack of caregiver support, difficulty coping/emotional, minimal or no family support, no spiritual support, unsafe family, etc.
Transportation: Transportation barriers may include limited vehicle access, medical transport required, no driver's license, no gas money, unable to drive due to illness, etc.
Work: Work barriers may include fear of losing a job, FMLA, lost job due to illness, no sick time, physically unable to work, etc.
Other: Other barriers could include: health management needs, in-home care needs, a lack of awareness or knowledge about legal status or rights, lack of access to prescriptions or supplies, or other barriers identified by the community member.
Describe other barrier(s) to cardiovascular screening .
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Direct Assistance Provided Does the barrier assessment demonstrate that there is a need for direct assistance beyond providing a resource list, referral to a health system or routine clinical practice?
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Yes
No
Did this participant want assistance?
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Yes
No
Select all screening types for which participant received direct assistance through TCO. You can return at any time to add additional screening types.
* must provide value
Select ALL types of direct assistance provided to this participant to access breast cancer screening .
Direct assistance should be separate from or in addition to actions performed as part of routine clinical services.
* must provide value
Breast cancer screening
DATE of the scheduled appointment (MM-DD-YYYY)
Only count if an appointment is scheduled by an outreach worker on behalf of the participant. Do not count if the participant schedules their own appointment or if clinical appointment services are scheduled directly with the participant.
STRONGLY ADVISED:
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Today M-D-Y
Breast cancer screening
CLINIC NAME where appointment was scheduled:
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Breast cancer screening
DATE appointment reminder sent (MM-DD-YYYY)
Only count if an appointment reminder is provided by an outreach worker. Do not count automated/ routine clinical appointment reminders.
* must provide value
Today M-D-Y
Breast cancer screening
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Breast cancer screening
Language in which assistance was provided
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Breast cancer screening
Type of transportation assistance:
Describe other transportation assistance:
Breast cancer screening
Describe other direct assistance:
* must provide value
Select ALL types of direct assistance provided to this participant to access cervical cancer screening .
Direct assistance should be separate from or in addition to actions performed as part of routine clinical services.
* must provide value
Cervical cancer screening
DATE of scheduled appointment (MM-DD-YYYY)
Only count if an appointment is scheduled by an outreach worker on behalf of the participant. Do not count if the participant schedules their own appointment or if clinical appointment services are scheduled directly with the participant.
STRONGLY ADVISED:
* must provide value
Today M-D-Y
Cervical cancer screening
CLINIC NAME where appointment was scheduled:
* must provide value
Cervical cancer screening
DATE appointment reminder sent (MM-DD-YYYY)
Only count if an appointment reminder is provided by an outreach worker. Do not count automated/ routine clinical appointment reminders.
* must provide value
Today M-D-Y
Cervical cancer screening
* must provide value
Provided by CHW (e.g., outreach worker directly provides assistance in participant's preferred/primary language)
Arranged by CHW (e.g., outreach worker coordinates language interpretation services, but does not directly provide assistance in participant's preferred/primary language)
Cervical cancer screening
Language in which interpretation was provided
* must provide value
Cervical cancer screening
Type of transportation assistance:
Describe other transportation assistance:
Cervical cancer screening
Describe other direct assistance
* must provide value
Select ALL types of direct assistance provided to this participant to access cardiovascular screening .
Direct assistance should be separate from or in addition to actions performed as part of routine clinical services.
* must provide value
Cardiovascular screening
DATE of the scheduled appointment (MM-DD-YYYY)
Only count if an appointment is scheduled by an outreach worker on behalf of the participant. Do not count if the participant schedules their own appointment or if clinical appointment services are scheduled directly with the participant.
* must provide value
Today M-D-Y
Cardiovascular screening
CLINIC NAME where appointment was scheduled:
* must provide value
Cardiovascular screening
DATE appointment reminder sent (MM-DD-YYYY)
Only count if an appointment reminder is provided by an outreach worker. Do not count automated/ routine clinical appointment reminders.
* must provide value
Today M-D-Y
Cardiovascular screening
* must provide value
Provided by CHW (e.g., outreach worker directly provides assistance in participant's preferred/primary language)
Arranged by CHW (e.g., outreach worker coordinates language interpretation services, but does not directly provide assistance in participant's preferred/primary language)
Cardiovascular screening
Language in which interpretation was provided:
* must provide value
Cardiovascular Screening
Type of transportation assistance:
Describe other transportation assistance:
Cardiovascular screening
Describe other direct assistance:
* must provide value
Cardiovascular screening
Total number of check-ins for self-measured blood pressure program/BP loaner program:
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Did the participant complete an office visit prior to a breast/cervical cancer screening?
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Office visit completed
Assisted directly to screen (no office visit)
Office visit not completed
Unknown after multiple contact attempts
Date office visit completed (MM-DD-YYYY)
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Today M-D-Y
Name of clinic where office visit completed:
* must provide value
Please explain:
* must provide value
The option "
Office visit resulted in:
* must provide value
How was office visit completion status determined?
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Verified through EHR/EMR/medical record
Accompanied participant to/from screening
Participant confirmed during follow up contact
Did the participant complete a mammogram?
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Mammogram completed
Mammogram not completed
Unknown after multiple contact attempts
Date mammogram completed (MM-DD-YYYY)
* must provide value
Today M-D-Y
Name of clinic where mammogram completed:
* must provide value
How was mammogram completion status determined?
* must provide value
Verified through EHR/EMR/medical record
Accompanied participant to and from appointment
Participant confirmed screening completion
Did participant have an abnormal result?
* must provide value
Yes
No
Did participant complete a diagnostic test?
* must provide value
Yes
No
Did the participant complete a pap and/or HPV test?
* must provide value
Pap and/or HPV test completed
Pap and/or HPV test not completed
Unknown
Date pap test completed (MM-DD-YYYY)
* must provide value
Today M-D-Y
Name of clinic where pap and/or HPV test completed:
* must provide value
How was pap and/or HPV test completion status determined?
* must provide value
Verified through EHR/EMR/medical record
Accompanied participant to and from appointment
Participant confirmed screening completion
Did participant have an abnormal result?
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Yes
No
Did participant complete a diagnostic test?
* must provide value
Yes
No
What is the status of the participant's cardiovascular screening (clinical appointment)?
* must provide value
Office visit completed
Office visit not completed after multiple contact attempts
Referred to Healthy Behavior Support Services
Date office visit completed (MM-DD-YYYY)
* must provide value
Today M-D-Y
Name of clinic where cardiovascular screening completed:
* must provide value
Date participant referred to Healthy Behavior Support Services (MM-DD-YYYY)
* must provide value
Today M-D-Y
Name of Healthy Behavior Support Service:
* must provide value
Participant feedback status
* must provide value
Participant provided feedback (e.g., through interview or survey)
Unable to collect client feedback
Please explain why you were unable to collect participant feedback
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SELECT THE PARTICIPANT'S RESPONSE TO:breast cancer screenings (such as an office visit/breast exam, or mammogram) on your own?
* must provide value
A lot. I am completely confident that I will complete future breast cancer screenings on my own.
A little. I am somewhat confident that I will complete future breast cancer screenings on my own.
Not at all. I am not confident that I will complete future breast cancer screenings on my own.
SELECT THE PARTICIPANT'S RESPONSE TO:cervical cancer screenings (such as an office visit/Pap Test) on your own?
* must provide value
A lot. I am completely confident that I will complete future cervical cancer screenings on my own.
A little. I am somewhat confident that I will complete future cervical cancer screenings on my own.
Not at all. I am not confident that I will complete future breast cervical screenings on my own.
ADD THE PARTICIPANT'S RESPONSE TO:
* must provide value
OPTIONAL
Submit
Save & Return Later
