Mobile Testing Requests

This request form is for the purposes of requesting to be a host of the IDPH mobile testing team to perform community COVID-19 testing on a specific date or set of dates at your location (ex. local community center, place of worship, company parking lot). This form is not needed to register for individual COVID-19 testing, as IDPH does not require registration for testing. If you are an individual looking to be tested for COVID-19, please visit dph.illinois.gov/testing and enter your address to find the sites nearest to you. Snow and ice removal is the responsibility of each mobile site host. Plowing and salting of the lot/venue should be completed prior to the arrival of the vendor or as soon as possible due to inclement weather.

Mobile Testing Population Size*

Please select which event track you'd like to register for. Small - to serve a populations not to exceed 100 Tests Medium - to serve a populations to serve a population of between 101 - 500 tests Large - Populations of higher than 500 tests to be given.

Small

Medium

Large

First Name of Mobile testing requester.*

Last Name of mobile testing requester.*

Job Title

Organizational affiliation of requester*

Select or enter value

Requester's Email Address*

Requester's Phone Number*

Requester's City*

Requester's Zip*

Is there a specific Date(s) for the testing team?*

Is there a specific location in mind?*

Select or enter value

How do plan on advertising for the event?

You may select more than one if necessary from the list below.

Select or enter value

Do you have partners that can help with adv.?

Please list community partners that could help with advertising the event.

Description of Site*

Describe the site with regard to visibility?*

e.g., at a busy intersection, easily identifiable location such as a school or mall.

Describe the site with regard to accessibility?*

e.g., near a bus stop, easy for residents to walk to.

Is the proposed site near another COVID test site?

Please let us know if the proposed site will be close to any other testing sites or locations by selecting yes or no below.

Select or enter value

Where is the closest testing site/location?

Address or location of the site?*

City or location for the mobile team?*

County the mobile team will be in?*

Testing Location Zip

Contact Full Name for this location*

Please enter the contact for the location here if it is different from the person submitting the form.

Contact email for the location*

Is the location a facility that will be tested?*

If this is a facility please select yes from the drop down so that our mobile team knows that they are testing an entire facility.

Select or enter value

Has a mobile testing been at this location before?

If the Mobile team has been at this location in the past select yes.

Select or enter value

How long will this testing be needed at location?*

Select or enter value

Please add additional information that is useful?

Send me a copy of my responses

Privacy Notice|Report Abuse