HIV/AIDS Counselor ID Request Form

CLIA/Rapid Test Training Request Form

All requests are completed in the order in which they are received. Please allow up to a week for processing.

* Denotes required fields.

* Requested by:

* Facility Name and Facility ID #:

* Please List the Staff you wish to have trained:

Enter staff here.

* Completion date of staff for: HIV/STD Basic Training Course 1 :

Completion date of staff for: HIV Prevention Behavior Change and Counseling Strategies Course 2:

* Phone Number:	* FAX Number:	* Email:
* Note -  In order to submit a request for these records online a FAX number and email address is necessary.

* Please indicate in the box below dates and times you are requesting training:

Enter dates and times here.

Questions: Contact (785) 296-4449 or Fax: (785) 296-4197