Kansas HIV Counseling and Testing Rapid

CLIA Incident Report


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Kansas HIV Counseling and Testing Rapid CLIA Incident Report

Kansas HIV/AIDS Program

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

* Denotes required fields.





Please indicate below the reason for submitting the Kansas HIV Counseling and Testing Rapid CLIA Incident Report:







If the Rapid HIV kit was invalid, faulty or defective was the client retested?

         


 

If YES, please indicate the HIV Test Form ID and Client ID used to re-test.



 

* Please describe the circumstances regarding the incident:



 If follow-up activities are required, please describe below:


PLEASE RETAIN A COPY OF THIS SUBMISSON FOR YOUR RECORDS


Questions: Contact Stephanie Green at (785) 296-5595 and the fax is (785) 296-5590.