Request for Rapid HIV Testing Supplies
HIV Early Intervention Services (EIS) Program

The HIV EIS program has a limited supply of rapid HIV testing supplies.
These are provided to eligible HIV EIS counselors at no charge.

Email address *
Name *
Your answer
Phone Number *
Your answer
Site Code *
Your answer
Worker ID *
Your answer
Facility *
Shipping Address *
Your answer
Is this a New Address?
Verification *
How many Test Kits (50 per box) are you requesting?
Your answer
How many Controls are you requesting?
Each Control Pack contains enough material to run controls approximately 20 times.
Your answer
You may request whatever quantity you need; if you are requesting more than 100, please explain:
Your answer
You agreed that you: *
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.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service