Collection Site Interest Form 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. OK Question Title * 1. Select your county from the drop down Alameda Alpine Amador Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Lassen Los Angeles Madera Marin Mariposa Mendocino Merced Modoc Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Stanislaus Sutter Tehama Trinity Tulare Tuolumne Ventura Yolo Yuba OK Question Title * 2. Please provide point of contact information Name Email Address Phone Number OK Question Title * 3. Please provide name and email address of an organization representative that will sign the Memorandum of Understanding (MOU) with the state Name Email address OK 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 OK Question Title * 4. Select your organization type from the drop down Local Health Jurisdiction (LHJ) Community Based Organization (Non-Profit) (Please specify) Employer (Please specify industry) Agriculture/ Food Processing Universities State facility (e.g. CalVet, State hospitals, CDCR etc.) Clinic/ Federally Qualified Health Center (FQHCs) Hospital Skilled nursing facility Residential care facility Churches/Faith Based Organization K-12 Independent School (i.e., not affiliated with School District / COE) Other Please provide details (if any) OK Question Title * 5. Which of the following best describes your organization? Nonprofit organization For-profit organization Other (please specify) OK Question Title * 6. Organization name (Provide full name, only list single organization) OK Question Title * 7. How many locations do you plan to provide testing in? OK Question Title * 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) OK Question Title * 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 No Yes OK Question Title * 10. What population(s) will be tested at the collection site? Employees/ staff members of organization Patients/ residents at facility General public Other (please specify) OK Question Title * 11. Which demographic group(s) will be tested? Communities of color Residents and/ or staff in congregate living facilities People experiencing homelessness Agriculture workers Food processing workers School staff (K-12) University staff Healthcare professionals Individuals with disabilities Immigrants or refugees Other (please specify) OK Question Title * 12. Primary reason(s) for interest in partnership with Valencia Branch Laboratory Expand testing to populations that are currently not being tested Increase testing frequency Improve turnaround time Find a cost-efficient solution Other (please specify) OK Question Title * 13. With what frequency do you plan on testing? Response driven testing, only if a positive case is identified Screening testing, once a week or more frequently Screening testing , every 2-3 weeks Screening testing, every month Other (please specify) OK Question Title * 14. What is your anticipated total weekly testing volume that you would like to send to the Valencia Branch Laboratory? OK Question Title Please use this information to help you estimate your organization's total weekly testing volume: OK Question Title The table below lays out the responsibilities of State vs. collection partner OK Question Title * 15. Does your organization have access to required technology? Please select all that apply. Tablets or laptops WiFi / Hotspots Scanner: Barcode scanner or ScanKey app Power cords For those areas where you do not have the required technology, are you confident you will be able to procure and access it ahead of testing? OK Question Title * 16. Does your organization have access to appropriate site locations? Please select all that apply. Appropriate site permits Indoor or outdoor physical space, with sufficient space for safe social distancing measures Bathrooms Waste disposal system Shelter Power If you do not have an adequate site identified, are you confident you will be able to identify one by the time you start testing? OK Question Title * 17. Does your organization have access to a reliable supply of PPE? Please select all that apply. Face masks Gloves (Medium and Large sizes are most popular) Face shields For those areas where you do not have the required PPE, are you confident you will be able to procure and access it ahead of testing? OK Question Title * 18. Does your organization have access to staff (~3 staff/ 250 participants)? Please select all that apply. Staff to help with intake for those not pre-registered (comfortable using technology) Staff to help supervise direct swabbing Staff for crowd/ flow control Shared provider for follow-up of positive cases (MD, DO, PA, NP or RN) Please provide specific details OK Question Title * 19. Are you currently testing at your organization(s) or have previous experience running a COVID-19 collection site? Yes No OK Question Title * 20. Do you currently or have previously partnered with your Local Health Department? Yes No OK Question Title * 21. How did you hear about partnering with the VBL? Testing Task Force (TTF) website Outreach from TTF representative (please specify name in Other option below) Local health office Outreach from other county office (please specify name in Other option below) Other (please specify) OK Question Title * 22. Additional comments OK NEXT