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.Format: (000) 000-0000.

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?

What is the size of your agency?

Do you provide Emergency Management Services in your region?

Other

Do you provide Community Paramedicine/Mobile Integrated Health Services?

Other

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

Other

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):

Other

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:

Other

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)

Other

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?

Other

What questions do you have at this time?

We will plan to address these during our kick-off call.

Date of submission

Date