If your organization is interested in partnering with CDPH and Valencia Branch Laboratory, please submit the interest form below. A representative will reach out to you shortly.
Note: This form has four pages. Please complete all four pages or your submission will not be considered.

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* 2. Please provide point of contact information

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* 3. Please provide name and email address of an organization representative that will sign the Memorandum of Understanding (MOU) with the state

If you are a K-12 school or school district, you should have received an email from the state's partner--Color--with specific instructions for schools. Please submit a request here https://www.color.com/cdph-site-support if you cannot find that email. If you are a K-12 independent school, please continue with this form

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* 5. Which of the following best describes your organization?

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* 6. Organization name (Provide full name, only list single organization)

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* 7. How many locations do you plan to provide testing in?

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* 8. Please enter the zip code for requested collection site.
(If testing at multiple locations, please enter zip code of primary location. Only enter 1 valid US zip code here)

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* 9. Are you planning to test at more than 1 location?

If Yes, List all additional zip codes you plan to test in (separated by commas)

Example: 51111, 51113, 51115

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* 10. What population(s) will be tested at the collection site?

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* 11. Which demographic group(s) will be tested?

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* 12. Primary reason(s) for interest in partnership with Valencia Branch Laboratory

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* 14. What is your anticipated total weekly testing volume that you would like to send to the Valencia Branch Laboratory?

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Please use this information to help you estimate your organization's total weekly testing volume:

Please use this information to help you estimate your organization's total weekly testing volume:

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The table below lays out the responsibilities of State vs. collection partner

The table below lays out the responsibilities of State vs. collection partner

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* 15. Does your organization have access to required technology? Please select all that apply.

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* 16. Does your organization have access to appropriate site locations? Please select all that apply.

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* 17. Does your organization have access to a reliable supply of PPE? Please select all that apply.

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* 18. Does your organization have access to staff (~3 staff/ 250 participants)? Please select all that apply.

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* 19. Are you currently testing at your organization(s) or have previous experience running a COVID-19 collection site?

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* 20. Do you currently or have previously partnered with your Local Health Department?

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* 21. How did you hear about partnering with the VBL? 

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* 22. Additional comments

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