Marin County BinaxNOW Antigen Testing Kit Agreement and Request Form
Testing requirements and details are available at
Facility name: *
Facility type: *
Primary point of contact (POC) name: *
POC title: *
POC email: *
POC phone number: *
The statements below are related to your facility's qualifications.
Does your facility have a Clinical Laboratory Improvement Amendments (CLIA) waiver? *
Does your facility have staff trained to properly administer the tests? *
Will your facility adhere to requirements to report test results to the California Department of Public Health (CDPH) using the CalREDIE Manual Lab Reporting Module (MLRM) within 8 hours of conducting the test? *
Has your facility submitted your institutional protocol for utilizing BinaxNow, reflecting adherence and understanding to the guidance above? [Send protocol to MHOAC via email, or fax, 415-473-3950.] *
Test kits come in boxes of 40.
Number boxes requested: *
Current stock of kits: *
If LTCF, current census:
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