CV19 – Medical Provider Testing Info Form – City and Borough of Juneau

Business Name*

Date of Data*

Name of person submitting form*

First Last

Type of Tests Offered*

Check all that apply.

PCR Send-Out
Abbott ID Now
Cepheid Xpert Xpress
Antibody
Other

PCR Send-Out

Current Supply of Test Kits (PCR Send-Out)*

For tests that have multiple components, enter the lower amount.

Test Kits on Order (PCR Send-Out)*

Anticipated Arrival Date (PCR Send-Out)*

How many tests per day can you process at your current staffing levels? (PCR Send-Out)*

Subjective sense of your ability to acquire more tests (PCR Send-Out)*

Can you acquire more, or are you being told that they are unavailable, being prioritized for other communities, market limited, or some other reason?

Abbot ID Now

Current Supply of Test Kits (Abbott ID NOW)*

For tests that have multiple components, enter the lower amount.

Test Kits on Order (Abbott ID NOW)*

Anticipated Arrival Date (Abbott ID NOW)*

How many tests per day can you process at your current staffing levels? (Abbott ID NOW)*

Subjective sense of your ability to acquire more tests (Abbott ID NOW)*

Can you acquire more, or are you being told that they are unavailable, being prioritized for other communities, market limited, or some other reason?

Cepheid Xpert Xpress

Current Supply of Test Kits (Cepheid Xpert Xpress)*

For tests that have multiple components, enter the lower amount.

Test Kits on Order (Cepheid Xpert Xpress)*

Anticipated Arrival Date (Cepheid Xpert Xpress)*

How many tests per day can you process at your current staffing levels? (Cepheid Xpert Xpress)*

Subjective sense of your ability to acquire more tests (Cepheid Xpert Xpress)*

Can you acquire more, or are you being told that they are unavailable, being prioritized for other communities, market limited, or some other reason?

Antibody

Current Supply of Test Kits (Antibody)*

For tests that have multiple components, enter the lower amount.

Test Kits on Order (Antibody)*

Anticipated Arrival Date (Antibody)*

How many tests per day can you process at your current staffing levels? (Antibody)*

Subjective sense of your ability to acquire more tests (Antibody)*

Can you acquire more, or are you being told that they are unavailable, being prioritized for other communities, market limited, or some other reason?

Other

Name of Test*

Current Supply of Test Kits (Other)*

For tests that have multiple components, enter the lower amount.

Test Kits on Order (Other)*

Anticipated Arrival Date (Other)*

How many tests per day can you process at your current staffing levels? (Other)*

Subjective sense of your ability to acquire more tests (Other)*

Can you acquire more, or are you being told that they are unavailable, being prioritized for other communities, market limited, or some other reason?

Anything else you want to share?

CAPTCHA

Medical Provider Information Form

PCR Send-Out

Abbot ID Now

Cepheid Xpert Xpress

Antibody

Other