Request for INSTI HIV Test Kits, Controls

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

HIV Early Intervention Services (EIS) Program

The Imagine Hope HIV Testing Program has a limited supply of rapid HIV testing supplies.
These are provided to partner agencies at no charge.

Email *

Name *

Phone Number *

Facility *

Address *

City *

Zip Code *

Is this a New Address?

Yes

Verification *

My agency can submit specimens to process confirmatory testing.

My organization has HIV testing quality assurance guidelines in agency policies & procedures.

Required

How many Test Kits are you requesting?

How many Controls are you requesting?

Each Control Pack contains enough material to run controls approximately 20 times.

You may request whatever quantity you need; if you are requesting more than 100, please explain:

You agreed that you: *

Yes

Have Completed INSTI HIV Testing and Prevention Counseling training

Have a system in place to confirm a preliminary positive

Have submitted a bubble sheet for every test conducted; I have no overdue bubble sheets

Submitted a Confidential HIV+ Consumer Served Today form (1 time only) for each HIV+ consumer that I have served - whether newly or previously diagnosed

Submitted an HIV+ Case Report form for each person I have diagnosed HIV-positive

Yes

Have Completed INSTI HIV Testing and Prevention Counseling training

Have a system in place to confirm a preliminary positive

Have submitted a bubble sheet for every test conducted; I have no overdue bubble sheets

Submitted a Confidential HIV+ Consumer Served Today form (1 time only) for each HIV+ consumer that I have served - whether newly or previously diagnosed

Submitted an HIV+ Case Report form for each person I have diagnosed HIV-positive

Please allow two weeks for delivery

You will be notified by e-mail when your request can be filled.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms