OTC Test Order (Legacy)

This order form is to be used by organizations that have received an invitation to partner with the State of California’s Testing Task Force (TTF) for COVID-19 antigen testing with At-Home (also known as Over the Counter, OTC, or Self-Test) tests.

To provide At-Home tests to Californians, the Testing Task Force has is working with several COVID-19 Testing Manufacturers. Your order will be filled based on existing inventory and you may receive a different brand of tests upon reorder. Instructions on how to run the tests will be provided with each test kit.

Please do not submit multiple orders. Your first order request will be sent to you as quickly as possible.

Please verify your order for accuracy before you submit. Once orders are approved, they cannot be changed or corrected.

Org Info

Organization Name

Please do not abbreviate or use acronyms

Org Type

Non-profit (NPO)
For-profit

Type of Organization

Other (please specify)

My organization has already tested with CDPH's Testing Task Force programs.

This includes the PCR, Supervised Antigen, and OTC testing programs.

Order Type

Is this your organization's first time ordering test kits (initial order) or is this a reorder?

TTF Unique ID (UID)

CDPH is now tracking organizations using a six digit UID. If you have not received your UID via email, or if you cannot locate it, please check the “I do not have it” box below.

I do not have/know my UID

Organization Point of Contact

First Name

Last Name

Email Address

Phone Number

Delivery Point of Contact

This point of contact person should:
- Be available at their contact number (direct cell phone) to coordinate delivery of testing materials; and
- Be available to receive shipments during working hours.

Delivery POC Same as Org POC

Delivery POC First Name

Delivery POC Last Name

Delivery Point of Contact Email

Delivery Point of Contact Phone

Must be a direct phone number to the individual listed above.
Please do not include a phone number that involves an extension.

Secondary Delivery Contact Name

Secondary Delivery Contact Phone

Must be a direct phone number to the individual listed above.
Please do not include a phone number that involves an extension.

Delivery Information

Please provide the address to which the order should be shipped.

Important:

~ Delivery address cannot be a P.O. Box
~ Delivery address must be in California
~ The Delivery Point of Contact must be available at this address to receive the shipment

Please review and verify the delivery address you entered is correct.
Any incorrect delivery information will result in delays to your delivery and delay testing at your site(s).

Please consolidate your order requests as much as possible. This includes shipping tests to a central location, such as a district office.
If you must have kits shipped to more than one location, please submit a separate order form.

Attention

Street

Building/Suite

City

Zip Code

County

Additional Delivery Instructions

Receiving Hours

Check this box if this an emergency order.

Orders are only considered an emergency if your organization will run out of testing supplies within 48 hours or if there is an outbreak at your organization which requires additional test supplies.

Please describe your organization's emergency needs.

Please note, the TTF will verify all emergency order prior to order fulfillment.

By when do you need the tests?

Please provide your best estimate for the number of tests required for an 8-week supply across all testing locations for your organization.

Based on supply availability, you may receive different test quantities than what your organization requests. Our team will work to get as close to the quantity you ordered.

Number of tests expected to be used by STAFF

Number of tests expected to be used by NON-STAFF

(e.g. students, clients, patients, visitors, etc.)

Total Test Quantity Requested

Additional Comments

Please confirm your understanding of the following:

I attest that these tests kits will be distributed to people who are uninsured or have limited access to healthcare resources.

I understand our organization cannot charge patients for COVID-19 testing performed through this program.

I understand our organization cannot bill patients' insurance for COVID-19 testing performed through this program.