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COVID-19 Antigen Test Kit Questionnaire & Request Form
Hello, please fill out the following form to request test kits. All requests must be picked up from our new location in Concord. For any questions, please reach out to heru.requests@cchealth.org
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* Indicates required question
Organization name:
*
Nombre de la organización
Your answer
Please enter your address:
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Por favor escriba su dirección
Your answer
Organization type:
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Tipo de organización
Your answer
Which area(s) of the County does your organization serve? (West, Central, East)
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¿A cúales area(s) del condado sirve su organización?
Your answer
To whom will these tests be distributed? (staff, high-risk populations, outbreak site, etc.)
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¿A quién se distribuirán las pruebas caseras?
Your answer
How will these tests be distributed? (distribution event date/location, etc.)
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¿Cómo se distribuirán las pruebas caseras?
Your answer
Person making request:
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Nombre de persona quien solicita pruebas caseras
Your answer
Best contact number:
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Por favor escriba su número de teléfono
Your answer
Email to be reached at: (for pickup instructions)
*
Por favor escriba su correo electrónico
Your answer
Quantity of tests needed (each):
*
Cantidad de pruebas caseras solicitadas
Your answer
Today's Date:
*
Fecha de hoy
MM
/
DD
/
YYYY
Comments/questions:
Comentarios o preguntas
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