Wisconsin COVID-19 Collection Supplies Request

This website is for qualified Wisconsin organizations only. If you are an individual experiencing COVID-19 symptoms, please visit wihealthconnect.com for more information and COVID-19 screening

Wisconsin COVID-19 Collection Supplies Request

Instructions

FOR IMMEDIATE OUTBREAKS CONTACT YOUR LOCAL HEALTH DEPARTMENT

The following supplies and services to facilitate laboratory COVID-19 testing are available at no charge to qualifying Wisconsin clinicians, local and tribal health centers, clinical laboratories, skilled nursing facilities, and other approved entities collecting specimens in response to COVID-19. The supplies and laboratory services are intended for the purpose of expanding Wisconsin’s existing COVID-19 testing capacity. Please do not use these supplies and services for the purpose of replacing your own existing testing resources. You may not bill third-party payors for these supplies and services (for more information about billing, click here).

The supplies and laboratory services are available for testing symptomatic and asymptomatic individuals based on clinical guidelines established by the organization requesting the materials.

Swabs Only: Nasopharyngeal (NP) swabs, Oropharyngeal (OP) swabs, or Nasal swabs alone, FDA approved.
VTM Only: Viral transport media 2-3 mL in plastic tubes.
Collection Supplies and Laboratory Services: Specimen collection materials including saline and a nasal swab. Room temperature storage. Testing at a state partnered reference lab.
COVID Connect/DTRA Labels: QR labels used for COVID Connect/DTRA testing events. NOTE: One unit is one pack (1500 labels). Partial units are not available.
POC Antigen Test Kits

Testing Plan - Please complete these questions to continue the request

Please provide a brief description of how the tests will be used.

Facility Type

To allow us to better track the distribution of testing supplies among the various types of health care providers in the State, please select from the provided drop down menu the type of health care facility that best describes on whose behalf you are placing your order.

Requester Contact Information

Enter your contact information, including your direct line phone number, to avoid delays should we need to contact you regarding details for your order.

Prefix

First Name

Last Name

Phone Number

Company or Organization

Address

Address 2

City

County

State

Zip Code

Shipping Information

Be sure to fill an appropriate shipping address (no PO Box address). Provide the name and phone number for the staff member responsible for receiving the shipment.

Prefix

First Name

Last Name

Company or Organization

Attention

Shipping Attention Phone Number

Address

Address 2

City

County

State

Zip Code

PCR Testing Supplies

Fill out the fields below for consideration of PCR Testing support

We will make every effort to send qualified organizations their preferred specimen collection materials. However, in the event that demand for particular materials exceeds current supply, we will send providers alternative materials if they can be utilized.

Number of Residents to be Tested

Number of Staff to be Tested

Testing Type

Please state which clinical laboratory will perform testing of specimens

Supplies

Antigen Testing Supplies

Qualified Wisconsin organizations can request antigen kits to provide onsite rapid testing.

If applicable, provide approximate amount of individual antigen tests in stock at your location.

Number of Antigen Tests Needed.

Provide CLIA Number for your Facility.

If you do not have a CLIA Number, please contact DHSDQACLIA@dhs.wisconsin.gov to apply for one.

Does your facility currently have access to PCR Testing services? (In-house, Contracted Lab, Community Testing, etc)

Notes

Notes or Comments (500 character max)

Terms of Acceptance of Specimen Collection Supplies and Laboratory Services

As a condition of receiving COVID-19 testing specimen collection supplies and/or laboratory services at no cost from the State of Wisconsin, you agree to:

Use and administer the specimen collection supplies and laboratory services only in compliance with all applicable laws, regulations, rules, authorizations, and guidance ("Applicable Law");
Have specimens collected by qualified personnel using proper procedures;
Ensure that personnel collecting specimens are trained in proper collection procedures;
For PCR testing, order laboratory services for such specimen in compliance with all Applicable Law;
For PCR testing, have laboratory services ordered only by authorized health care professionals;
Communicate results of COVID-19 tests in compliance with all Applicable Law; and
Obtain all necessary consents and authorizations from patients to perform services and release the results of those services to the Wisconsin Department of Health Services (DHS) or its designees.
Order only the supplies and/or related laboratory services necessary to meet your needs over the next 7-14 days.
Account for unused supplies and report to the State upon its request. The State reserves the right to have unused supplies returned to the State.

You also agree not to:

Bill third parties for the specimen collection supplies and laboratory services; or
Use the specimen collection supplies and laboratory services to provide COVID-19 testing services to State of Wisconsin government entities, including but not limited to universities in the University of Wisconsin System, unless otherwise agreed to in writing by the DHS or the Wisconsin Department of Administration.

I Accept The Terms Outlined Above

Contact Information
Email: wicovidtest@wisconsin.gov