Rapid HIV/HCV/Syphilis Testing Order Form

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Thank you for your interest in accessing free HIV, HCV and/or Syphilis Rapid Tests. Please fill out the form below. All questions are mandatory. After submitting this form, someone from CDPHE will be revising your “distribution plan”, and making a decision on your order. Please allow up to 7 days for your order to be processed. CDPHE will notify you once your order has been approved and shipped.

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E-Mail-Adresse *

Agency Name *

Shipping Address (please include city and zip code)

Contact Name *

Email Address *

Does your agency currently receive funding to provide STI/HIV testing from CDPHE or CDC? If so, you may not eligible for this program. If you answer is yes, please explain why you are requesting these tests. *

Which type of rapid test is your agency requesting? *

OraQuick HIV (Provider Adminstered) (orders come in sets of 6)

Insti HIV (orders come in sets of 50)

Syphilis Health Check (orders come in sets of 20)

OraQuick HCV

OraQuick HIV (Self-Collected/At-Home)

Chembio (Rapid HIV/Syphilis combo) (orders come in sets of 20)

Alere HIV (orders come in sets of 25)

Pflichtfrage

Do you need External Controls?

Yes

Not at this time

Auswahl löschen

Number of tests requested. If you selected multiple test types, please make sure to indicate how many of each test. *

Tests needed by (Date): *

Datum

Describe, in detail, how these tests will be utilized *

Describe your agency's process for confirmatory testing and linkage to care/treatment. *

Does your agency have an active CLIA waiver on file? If no, you are not eligible for this program.

Please note: Agency must email their CLIA waiver to garrett.rose@state.co.us (one time only)

Yes, we have a CLIA Certificate

Yes, but we need to update our CLIA Certificate

No, we don't currently have a CLIA Certificate

Has your agency reviewed CDPHE Standards for HIV/STI/VH Prevention *

My agency has reviewed and agrees to CDPHE's Standards for HIV/STI/VH Prevention

My agency agrees to follow reporting guidelines for all positive results (both rapid and confirmatory) *

My agency agrees to follow reporting guidelines

Agencies will be required to complete a short REDCap form to document the number of tests provided, test results and distribution plan (no client demographics will be required). *

My agency agrees to submit a REDCap survey

Agencies receiving free rapid syphilis test kits will be required to sign up for our Colorado STI/HIV Testing & Treatment Locator *

My agency has completed the Syphilis Testing & Treatment Locator form

No - requesting tests for Jail screening only

No - requesting tests for TB screening only

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Dieses Formular wurde bei State.co.us Executive Branch erstellt.

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