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

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*

School Information

School District Name*

School Name*

School Address*

City*

State

Select

Zip Code*

County*

Select

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.*

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