You must have JavaScript enabled to use this form. Please complete this form to request COVID-19 testing. Requests should be submitted at least two (2) weeks in advance of proposed event date. Completion of the form does not guarantee testing. Name of Requesting Organization Name of Requestor Requestor Phone Number Requestor Email Proposed Testing Location Name Unknown Testing Location Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Location Type (check one) Building Parking Lot Unknown Other… Enter other… Type of Request (check one) Unknown at this time One-Time Event (indicate proposed date below) Recurring Request (indicate proposed dates below) One-Time Event Date Recurring Request Dates Recurring Request Dates Recurring Request Dates Item weight Remove Date 1 Add Next Date(s) Add Next Date(s) Priority Population (check all that apply) Healthcare Workers/Essential Workers Schools (check one below) Seniors Genreral Public Location requires a walk up site Other… Enter other… Schools (check one) K-12 Higher Education Approximate Number of Anticipated Participants Unknown Number of Participants Testing Requested (check one) PCR Rapid Antigen Saliva No Preference/Not Sure Primary Contact for Day-Of Event Primary Contact Phone Number Primary Contact Email Event Information (please check all that apply) Collaboration with School (list below) Collaboration with City/Government (list below) Collaboration with Other Partner (list below) Requires Bilingual Staff (indicate languages below) Other… Enter other… Collaboration with School List Collaboration with City/Government List Collaboration with Other Partner List Language List Brief Reason for Event Additional Event Information Submit
