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2. All orders will be shipped within 3 business days of submission.

4. Facility ID Number
5. Facility Name*
7. Name*
8. Email Address*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
18. Do You Need Health Submission Forms?
    -- Select One --YesNo
20. Health Submission Forms

    1. Universal Specimen Submission Forms

    1. Neonatal Screening & PKU Monitoring

    1. Neonatal Brochure
22. Universal Specimen Submission Forms

    Amount

23. Neonatal Screening & PKU Monitoring

    Amount

24. Neonatal Brochure (English)

    Amount

25. Neonatal Brochure (Spanish)

    Amount

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

    Enter amount needed in the boxes below.

29. Chlamydia/Gonorrhea Shipper

    Ambient Multi-tube Container with Mailing Box 

30. Mailing Cooler (Cold shipper)

    Valid for ALL Serology and Viral Specimens

32. Nasopharyngeal Swab Kits

    Swabs and VTM packaged together

33. Anterior Nasal Swab Kits

    Swabs and VTM packaged together

    
    

34. Quicksal Oral Rinse

    (Valid for COVID only)

36. Monkeypox Collection Kit

    (Swabs, empty tubes & specimen bags)

37. Nasopharyngeal Swab

    (For Viral specimen collection)

38. Viral Transport Medium

    (VTM)

40. Serum Collection SST tubes

    (Gold-top)

41. Screw-cap Serum Tubes

    (Pour off Tube)

42. Specimen Transport Bags
44. EDTA Purple Top Blood Tubes

    (Venous Blood Metals)

45. K2 EDTA Microtainer

    (Capillary Blood Metals)

46. Lancet

    (Capillary Blood Lead collection only – not NBS)

48. TB Mailer

    (with Sputum Collection tube)

49. Blood – Ambient, Valid for QFT

    Multi-tube Container with Mailing Box

50. QuantiFERON
    -- Select One --YesNo

    (QFT tubes only)

52. QFT Tube Amount
54. Category B Enteric Mailer with Cary Blair
55. Ambient Miscellaneous Category B Shipper
56. Category A / IDS Mailer Bacterial Isolate
58. Other

    Please Specify

60. Do You Need Rapid COVID-19 Test Kits?
    -- Select One --YesNo

    Enter amount needed in the boxes below.

    
    

62. Type Needed

    1. Rapid Point of Care Antigen Cards
    2. BD Veritor Test Kits
    3. Over the Counter

    **UPDATE: BD Veritor Test Kits Require an Analyzer. KDHE will no longer provides analyzers. Analyzers are available for purchase through a variety of vendors. **

64. Rapid Point of Care Antigen Cards Test Amount Need
66. Are You A Volunteer Testing Partner?*
    -- Select One --YesNo
68. Over The Counter Test Amount Needed
70. Over The Counter Test Amount Needed
72. BD Veritor COVID/Flu Test Amount

    **UPDATE: BD Veritor Test Kits Require an Analyzer. KDHE will no longer provides analyzers. Analyzers are available for purchase through a variety of vendors.**

74. CLIA Waiver Number:*
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field