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2. Each facility must ensure they meet the following program requirements before submitting a request through this portal.  The DuPage County Health Department will not be providing technical support (i.e., CLIA application guidance or standing orders to perform point-of-care [POC] COVID-19 testing) to assist you in meeting these program requirements. 

4. Organization Name:*
6. First Name:*
7. Last Name:*
9. Address:*
11. City:*
12. State:*
13. Zip Code:*
15. Email:*
16. Phone Number:*
18. Description of Request (Please include how many test kits you are requesting and how often you plan to request test kits from the health department.)*

20. **Please note, during times of low supply, the DuPage County Health Department will review and fill requests based on priority need. This will include prioritizing the following: 

    • Schools
    • Veteran homes
    • DHS/DCFS/DJJ facilities
    • Long-term care and assisted living facilities who are supplementing allocation limitations from HHS
    • Facilities experiencing outbreak activity

    This resource is temporary and extremely limited, meaning distribution is not guaranteed. IDPH has expressed that supply limitations currently restrict local health departments from supporting employee testing programs. We strongly encourage all requesting organizations to secure alternative plans for COVID-19 testing. 

    
    

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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

* indicates a required field