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

KDHE Home - Health - BDCP - HIV/AIDS Program - - Orasure/Rapid Test Device Request Form

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 #:

* 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 (785) 296-4449 or Fax: (785) 296-4197