Antigen Home Test Kits Request Form

Dear Community Partner:

Ventura County Public Health is enlisting your support in helping distribute COVID-19 home test kits to uninsured individuals who do not have Medi-Cal, Medi-Care, or private insurance and who live or work in Ventura County.

We are asking for your support in distributing the COVID-19 home test kits to your clients. If you are interested, you may submit your request below. Once you have submitted your request, you can expect a call from a Public Health Team Member within 24 to 48 hours.

For questions, comments, or more information, please contact: rapidtestrequest@ventura.org

Finally, all organizations receiving tests are encouraged to ask test users to activate CA Notify and report positive tests via CA Notify.

Test kits are available through the California COVID-19 Testing Task Force.

Attention: These kits are to be distributed to the community and should not be used for routine surveillance testing of staff.

Organization Name:*
Please enter the name of the organization requesting the test kits.
Organization type:*
Please specify:
Federal Tax/501c3 ID:*
County:*
Organization Website
Address:*
Please enter the address of the organization requesting the test kits.
City*
Please enter the city of the organization requesting the test kits.
Zip Code*
Please enter the zip code of the organization requesting the test kits.
Distribution Site Address:
Please provide the distribution site address if different than the organization address.
Distribution Site Zip Code
Contact Name:*
Please enter the name of the person who may be contacted regarding this request.
Contact Phone Number:*
Please enter the phone number of the person who may be contacted regarding this request.
Contact E-mail:*
Please enter the e-mail of the person who may be contacted regarding this request.
What is the number of the population you intend to serve?*
Each test kit contains two tests.
Date of Test Distribution:*
Date Format: MM slash DD slash YYYY

Please enter the date you anticipate distributing all of the test kits. Ideally, it will be within 5 days from when you pick up your order.
Accepted Use Acknowledgment*
- I acknowledge.
I acknowledge that these test kits are not for personal use. Nor will they be used for surveillance testing of employees.
Zero Cost Acknowledgment*
- I acknowledge.
I acknowledge that there is no charge for these test kits and that they will be distributed free of charge.
Describe your plan on how these will be distributed to the community.*