K-12 COVID-19 iHealth Self-Test Registration Form

Once the registration form is complete, please fill out the order form to receive testing kits to your district office.

Link to order form https://app.smartsheet.com/b/form/831e6bd4db324072b7720b6e64fcfa42

Date

mm/dd/yyyy

School Information

School District Name

School Name

School Address

City

State

Zip Code

County

Student Enrollment for 2021-2022 School Year

Total Staff Employed for 2021-2022 School Year

School Testing Administrator Information

The school testing administrator will be the person responsible for the maintaining and distributing the iHealth self-test. Orders for the self-tests must be placed at the district level.

Name of School Testing Administrator

Email of School Testing Administrator

Phone Number of School Testing Administrator

Please check below next to each statement.

Requirement for in-person instruction: I attest that the school listed above is currently serving students in limited or full in-person instruction. I understand that participation of the school listed above in future testing opportunities is not guaranteed.

Testing Strategy attestation: I attest to use the iHealth self-test to support the testing of individuals with symptoms or exposure. I acknowledge that these test must be distributed to families for at-home testing.

Send me a copy of my responses

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