Request for INSTI HIV Test Kits, Controls
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 address *
Name *
Phone Number *
Site Code *
Worker ID *
Facility *
Address *
City *
Zip Code *
Is this a New Address?
Verification *
Required
How many Test Kits (50 per box) 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
No
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.
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