LeadingAge CLIA Certificate Information Collection

Please fill out this Google Form within 2 weeks, but the sooner you get this information back to us, the sooner we can work to advocate for testing supplies to be sent to your organization (and the more likely you will receive tests). We want to reiterate that unless you upload a copy of your CLIA certificate along with filling out the form, your organization will not be eligible to receive tests.

1. Organization name

2. Point of contact

3. Point of contact email address

4. Address where you want the tests shipped

5. Total number of staff (home health and hospice)

6. Total number of patients served per month (home health and hospice)

7. Please be sure to upload a copy of your CLIA certificate or your organization will not be eligible to receive tests.

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8. Who is/are your supplier(s) for PPE?

9. Are you having trouble obtaining PPE? Please indicate what types.