COVID-19 Testing Request Form | The Health Collaborative

Contact Name*

First Last

Organization or Testing Site Name*

Contact Email Address*

Phone Number*

Organization Address*

Street Address Address Line 2 City State ZIP Code

Neighborhood where testing will take place:

County where testing will take place:

Please check the type of organization that is requesting COVID-19 testing.*

(Check all that apply)

If other, please describe:

Please briefly describe the population to be tested:*

Please indicate if the population to be tested includes any of the following groups:*

(Check all that apply)

Frontline or Essential Workers (e.g. food service, teachers, public transportation providers, mail carriers, etc.)
First Responders (e.g. police, EMS, fire fighters, etc.)
Racial and ethnic minorities
Individuals disproportionately affected by poverty, limited medical insurance
Individuals disproportionately suffering from substance use or mental health disorders
Individuals disproportionately affected by chronic medical conditions
Individuals over the age of 65
None of the above

Estimated number of people to be tested:*

Approximately how many confirmed or suspected (symptomatic but not confirmed) cases of COVID-19 are you aware of in this setting or population over the past 5 days?*

(If none please respond with zero)

Approximately how many confirmed or suspected exposures to COVID-19 are you aware of in this population or setting over the past 14 days?*

An exposure is defined as close contact (less than 6 feet for 15 or more minutes) with someone who developed symptoms or tested positive for COVID-19 with no symptoms within 2 days after the contact. If none please respond with zero.

Do you anticipate needing interpreters on site for testing?*

Yes
No
Don't know/not sure

Is this request for testing at an event that is already scheduled?*

Yes
No

If Yes, please list the date and event name here:

How did you hear about Test and Protect?

If other, please describe: