2022-23 California K-12 School Over-the-counter (OTC) /At-Home Test Order Form

For Pasadena, Long Beach, and all other California schools outside of Los Angeles County.*

*Los Angeles County schools/organizations (public, private, and charter) excluding the cities of Pasadena and Long Beach have their own program. Please do not use this form; email for support.

Tests are intended for distribution to K-12 students, teachers and staff and affiliated on-campus programs (may include younger children in these programs)
Tests are distributed in boxes. Each box may contain either 1 or 2 tests
Only schools may place an order, but they may order additional tests to support on-campus child cares, afterschool programs and school-related camps

Please consolidate orders. When possible, ship to a central location, such as a district office, rather than individual schools. Contact schoolotc@cdph.ca.gov within 24 hours if changes are needed. Allow 14 days for shipping.

Test Storage

Tests must be stored indoors and temperature-controlled (Range 35.6-86°F)
Test brand may vary. Plan storage space for a 4x4x6 foot pallet for each 1,440 tests.

At-Home (OTC) Tests are Self-tests
Test must be performed (both the test process and the result) by the individual (or their parent/guardian). They cannot be performed on others by school staff—if you need to test others, you must use different tests after training. Apply here.

Order At-Home Tests here:

Organization Name

Please do not abbreviate or use acronyms

Type of Organization

Other Org Type

Does your organization primarily serve K-12 students?

Some/All Tests are for Summer Camp/School

YesNo

Number of School Sites Served

Total Student Population

Is this your organization's first time ordering Over-the-Counter (OTC)/At-home test kits for the 2022-23 school year (initial order) or is this a reorder?

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

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

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

Verify 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:

~ These are large orders and cannot be delivered to P.O. Boxes
~ 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

Receiving Hours

Additional Delivery Instructions

Order Quantity Instructions

Please order a 12-week supply of OTC test kits for your school/school district. Please order the total number of tests needed for each individual to receive two tests each (note that some tests come in single boxes and others come in 1-2 tests to a box).

Ex: order 180 tests for a school with 90 students.

Total number of tests requested for on-campus childcare and/or camps (Enter 0 if zero tests are requested)

Total number of tests requested for district/school testing

OTC Test Quantity Requested

Additional Comments

Please carefully review your order information before clicking "submit". Once orders are placed, they cannot be changed or cancelled, so please verify your order for accuracy before you submit.

I attest that I understand the following:*

At-home (OTC) tests are self-tests to be used by an individual (or parent/guardian). Tests must be completed (including result interpretation) by the individual or parent/guardian.
School staff cannot use at-home (OTC) tests to perform or read/interpret results on other people (i.e., students, other staff).
Self-reporting at-home (OTC) test results in Primary.Health is strongly encouraged, but not required.
Schools enrolled in Primary.Health can view results self-reported by individuals to track COVID-19 cases. Enroll here.