State of Connecticut - Respiratory Collection Supplies Request Form

Purpose: The purpose of this form is enable authorized testing locations to request testing supplies from the State of Connecticut.

Deadline: All requests must be submitted at least three (3) business days prior to the scheduled testing date.

Date of Request*

Organization/Business Name*

Street Address*

City*

State*

Zip*

Point of Contact First Name*

Point of Contact Last Name*

Point of Contact Direct Phone Number (XXX) XXX-XXXX*

Point of Contact Email Address*

Type of Organization*

If 'Other', List Organization Name*

What group of people is being tested?*

If testing for other, list group*

Are you partnered with a testing lab?

Yes No *

If you are partnered with a testing lab please list lab name here*

What is the scheduled testing start date?*

Number of people estimated to be tested*

Type of swab requested*

Type of transport media*

Remel VTM specified tube size*

Number of Respiratory specimen collection kits. (This includes 1 swab and 1 vial) *

Requestor Comments