Kansas Department of Health and Environment: Orasure/Rapid Test Device Request Form

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Orasure/Rapid Test Device Request Form

All Test 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 #:

* Facility mailing address:

* Type of Test Device (Orasure or Rapid) and amount needed:

* Please specify the number test devices, rapid and/or Orasure, you currently have:

* 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:

Please indicate if you are needing controls here.

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

* Select the ones that apply to you: My facility administers HIV testing through...

Rapid Tests
Venipuncture
Orasures

Questions: Contact Jamie Flemming at (785) 296-6545 or Fax: (785) 296-4197.