Interest form for local health jurisdictions (LHJs) interested in setting up new or modifying existing OptumServe resources

Before completing the survey, please refer to this catalog for an overview of OptumServe resources available. Please submit a new form for each requested resource. Note: New options were added in January 2021

If you are interested in changing locations, reducing operating hours or decreasing capacity at one of your existing OptumServe test sites, please complete the request for support via OptumServe request form and email it to GroupEventsAdminmailbox@Logisticshealth.com and cc testing.taskforce@state.ca.gov.

Note: This form is intended only for Local Health Jurisdictions interested in requesting new additional OptumServe resources, modifying an existing OptumServe resource or prior OptumServe request. If you are not an LHJ or you are an LHJ interested in setting up a non-OptumServe site, please fill out this interest form instead.

Question Title

* 1. Select your local health jurisdiction (LHJ) from the drop down

Question Title

* 2. Please provide LHJ point of contact information

Name

Email Address

Phone Number

Question Title

* 3. Select type of request

Request modification to existing OptumServe resource or prior request

Request new OptumServe resource