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2. Facility ID Number
3. Facility Name*
5. Name*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
16. Do You Need Health Submission Forms?
    -- Select One --YesNo
18. Health Submission Forms

    1. Universal Specimen Submission Forms

    1. Neonatal Screening & PKU Monitoring

    1. Neonatal Brochure
20. Universal Specimen Submission Forms

    Amount

21. Neonatal Screening & PKU Monitoring

    Amount

22. Neonatal Brochure (English)

    Amount

23. Neonatal Brochure (Spanish)

    Amount

25. Do You Need Health Specimen Kits & Supplies?
    -- Select One --YesNo

    Enter amount needed in the boxes below.

27. Chlamydia/Gonorrhea Shipper

    Ambient Multi-tube Container with Mailing Box 

28. Mailing Cooler (Cold shipper)

    Valid for ALL Serology

30. Monkeypox Collection Kit

    (Swabs, empty tubes & specimen bags)

31. Nasopharyngeal Swab

    (For Herpes specimen collection)

32. Viral Transport Medium

    (VTM)

34. Serum Collection SST tubes

    (Gold-top)

35. Screw-cap Serum Tubes

    (Pour-off tube)

36. Specimen Transport Bags
38. EDTA Purple Top Blood Tubes

    (Venous Blood Metals)

39. K2 EDTA Microtainer

    (Capillary Blood Metals)

40. Lancet

    (Capillary Blood Lead collection only – not NBS)

42. TB Mailer

    (with Sputum Collection tube)

43. Blood – Ambient, Valid for QFT

    Multi-tube Container with Mailing Box

44. QuantiFERON
    -- Select One --YesNo

    (QFT tubes only)

46. QFT Tube Amount
48. Category B Enteric Mailer with Cary Blair
49. Ambient Miscellaneous Category B Shipper
50. Category A / IDS Mailer Bacterial Isolate
52. Other

    Please Specify

54. Do You Need COVID-19 Health Specimen Kits?
    -- Select One --YesNo

    Enter amount needed in the boxes below.

    
    

56. Type Needed

    1. Collection Supplies
    2. Accula Point of Care PCR Supplies

    1. Rapid Point of Care Antigen Cards
    2. BD Veritor Supplies

    1. Over the Counter
58. Quicksal Oral Rinse
59. Nasopharyngeal Swab Kits
60. Anterior Nasal Swab Kits
62. Rapid Point of Care Antigen Cards Test Amount Need
64. Are You A Volunteer Testing Partner?*
    -- Select One --YesNo
66. Over The Counter Test Amount Needed
68. Over The Counter Test Amount Needed
70. Do You Need An Accula Instrument?
    -- Select One --YesNo
72. Accula Test Amount
73. Amount of Accula Instruments Needed
75. Do You Need A BD Veritor Instrument?
    -- Select One --YesNo
77. BD Instrument Amount
79. BD Veritor COVID/Flu Test Amount
80. BD Veritor Flu A+B Test Amount
81. BD Veritor RSV Test Amount
82. BD Veritor Strep Test Amount
84. CLIA Waiver Number:*
Leave This Blank:


86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

* indicates a required field