WA COVID-19 Interest Form

WA COVID-19 Interest Form
WA COVID-19 provides First Responders with the supplies, funding, and support you need to setup lightweight COVID-19 testing. This program is sponsored by Washington State Department of Health (DOH) and operated by Health Commons Project.

If you are a First Responder Agency in Washington State and you are interested in learning more about the program, please complete this short interest form. The form has 20 brief questions (most are multi-choice) and will take approximately 5-10 minutes to complete.

Once you submit the form, a Program Manager from Health Commons Project will reach out to schedule a call to learn more about your agency and the COVID-19 testing services you would like to implement.

If you have questions or concerns, please contact us at hannah@healthcommonsproject.org.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Title/Role*
Organization Name*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization Mission/Vision*
You are welcome to add a link to this information on your website if available
What counties are you licensed to operate in?*

Adams CountyAsotin CountyBenton CountyChelan CountyClallam CountyClark CountyColumbia CountyCowlitz CountyDouglas CountyFerry CountyFranklin CountyGarfield CountyGrant CountyGrays Harbor CountyIsland CountyJefferson CountyKing CountyKitsap CountyKittitas CountyKlickitat CountyLewis CountyLincoln CountyMason CountyOkanogan CountyPacific CountyPend Oreille CountyPierce CountySan Juan CountySkagit CountySkamania CountySnohomish CountySpokane CountyStevens CountyThurston CountyWahkiakum CountyWalla Walla CountyWhatcom CountyWhitman CountyYakima County
What is the size of your agency?*
Do you provide Emergency Management Services in your region?*

YesNoOther
Do you provide Community Paramedicine/Mobile Integrated Health Services?*

YesNoOther
Do you currently have a Medical Test Site (MTS) License Waiver for COVID-19 testing?*

YesNoDon't knowOther
Which of the following best describes the role that your organization has played in the response to the COVID-19 Pandemic (select all that apply):*

We have delivered COVID-19 testing services to our community membersWe have delivered COVID-19 vaccination services to our community membersWe have delivered other COVID-19 countermeasures (information, masks, food, etc) to our community membersWe have not delivered COVID-19 testing, vaccination or other countermeasures to our community membersOther
Which of the following best describes the role that your organization would like to play when it comes to mitigating the impact of COVID-19 on the community you serve:*

We want to launch new COVID-19 testing servicesWe want to sustain or improve our existing COVID-19 testing servicesOther
Please provide a brief description of the unmet needs in your community when it comes to COVID-19 testing, vaccination, and related services:*
Please provide a brief description of the existing & previous services your agency is providing when it comes to COVID-19 testing, vaccination, and related services:*
Please provide a brief description of the COVID-19 testing services you would like to implement:*
We recognize there are many different use cases for COVID-19 testing. Would you be interested in implementing any of the following testing services? (select all that apply)*

Distribution of over-the-counter test kits at community eventsDistribution of over-the-counter test kits to priority populations in partnership with other trusted stakeholders (i.e., schools, community health workers)In-transit/Ambulance testingMobile testing (i.e., providing testing when responding to a call)Testing homebound adults or other vulnerable populations who cannot proactively seek testingOutbreak testing at local schools, agricultural settings/farms, congregate living settingsOther
Please provide a brief description of the benefits of your proposed COVID-19 testing solution(s):*
Will you need funding to offset costs related to providing COVID-19 testing to your community members?*

YesNoUncertain at this timeOther
What questions do you have at this time?
We will plan to address these during our kick-off call.
Date of submission

MonthDayYear
Date
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