DetectNWT Rapid Antigen Test Program Application Form

DetectNWT Rapid Antigen Test Program

Application Form

Please complete and submit this form. Note that all fields are required.

Organization Name*

Organization Type*

Please select the grouping that best describes your organization

Select or enter value

Organization Eligibility Tier*

Please refer to the Eligibility Tier List at DetectNWT (Nthssa.ca/en/detectnwt-eligibility-tier-list)

Select

City/Community*

Please list your organization's primary location

Physical location(s), including street address(es) where your organization will deploy screening tests.*

Name of key contact*

Key Contact's Phone*

Phone

Key contact's email address*

Type of population to be screened (e.g., employees, contractors)*

Frequency of screening*

Select

Total # of Individuals Screened Weekly*

Number of tests needed per month*

This should reflect the number of individuals and frequency of testing

Number of staff to be trained in rapid antigen testing*

https://www.nthssa.ca/en/detectnwt-program-terms-and-conditions

Checking this box confirms that the participating Organization agrees to comply with the Program Terms and Conditions*

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