Covid-19 OTC Test Kit Request Form

IMPORTANT NSTRUCTIONS - PLEASE READ BEFORE COMPLETING THIS FORM

The State of Minnesota is making Covid-19 OTC tests available for use by students/staff at no cost through the 2023-2024 school year.

Schools can request tests per student/staff based off of 100% Fall 2020 enrollment. Schools are encouraged to order as a district.

Child Care Programs can request tests per student/staff based off of 100% licensing capacity and will receive Covid-19 OTC tests.

If a school/child care orders 140+ boxes of tests, the school/child care will be responsible for picking up the tests. The warehouse does not have the capacity to deliver large quantities of tests.

If your schools is not listed in the drop down please select "other" and type in the name of the school.

Who are you ordering for?

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School district, charter school, tribal school, K12 Child Care, or non-public school

Child care program (licensed or certified): NON K-12

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School Name

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Please specify

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Child Care Program Name

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Please input your license number (child care license ID)

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Please enter your licensing capacity

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Please enter your current enrollment number

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Please enter the number of program staff

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Boxes of Orasure InteliSwab (24 test kits per case)

Please order by the number of cases. One case = 24 test kits

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*First Name

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*Last Name

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Full Name

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Phone

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Street Address (no PO Boxes)

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City

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State

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Zip code

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Boxes of Orasure InteliSwab OTC Test kits (24 test kits per box)

Please order by the number of boxes. One box = 24 test kits.

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I agree that the testing supplies provided by the Minnesota Department of Health ("MDH") under this
program are provided "as is." MDH makes no representations or express or implied warranty as to
the condition, effectiveness, or safety of the testing supplies provided under this program. MDH shall not be liable for special, consequential or incidental damages attributed to use of the testing supplies or kits provided under this program.

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Add signature

Date and Time

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M-D-Y H:M:S

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