Residential Youth Facilities BinaxNOW Registration

Residential Youth Facilities BinaxNOW Registration

Date*

Facility Information

Name of Facility*

Shipping Address*

Please note that we cannot mail to PO Boxes

City*

Zip Code*

County*

Select or enter value

Staff and Student Information

Youth Enrollment*

Number of Staff*

Testing Administrator

The testing administrator will be the person responsible for observing specimen collection, performing the Abbott BinaxNOW rapid-point-of-care antigen test, and logging results

Name of Testing Administrator*

Email of Testing Administrator*

Secondary Testing Administrator

Phone Number of Testing Administrator

Email of Secondary Testing Administrator

Phone Number of Secondary Testing Administrator

Testing Reporter Information

The testing reporter will be responsible for all COVID-19 testing consent forms and reporting requirements.

Name of Testing Reporter*

Email of Testing Reporter*

Phone Number of Testing Reporter*

Name of Secondary Reporter

Phone Number of Secondary Reporter

Email of Secondary Reporter

Please complete the below attestation.

Training Attestation: I attest that the testing administrator has read the testing guidance in full and has completed the Abbot BinaxNOW training modules.*

Consent Attestation: I attest that the testing reporter and testing administrator understand that testing may only be performed for youth ages 15+ and staff who giver verbal consent. Any youth under age 15 must have consent on file.

Reporting Attestation: I attest that the testing reporter has read this guidance in full, that COVID-19 test results will be reported daily, and that the Abbott BinaxNOW testing log will be updated as each test is performed.*

Testing Strategy Attestation: I attest that the facility listed above will follow OHA testing guidelines and test only symptomatic and exposed youth and staff, or test youth upon entry or reentry to facilities. The facility will not use the supplied Abbott BinaxNOW test kits otherwise perform "screening" test on people without symptoms and no known exposure to COVID-19.*

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