Kansas Department of Health and Environment: HIV/AIDS Counselor ID Request Form

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HIV/AIDS Counselor ID Request Form

All Counselor ID 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 and Facility ID #:

* Completion date of the: HIV/STD Basic Training Course # 1 REVISED 2008 (Web-based) (1007721):

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

Comments or Questions::

Enter comments or questions here.

( * At least one selection below is required before submittal. )

* Select the ones that apply to you: I administer HIV testing through.
Rapid Tests
Venipuncture
Orasures

Questions: Contact Jessica Schmelzle at (785) 296-8819 or Fax: (785) 296-4197.