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Asymptomatic/Serology COVID19 Testing Request Intake

1. Company Name *This question is required.

2. Company Contact Person *This question is required.

3. Company Email *This question is required. This question requires a valid email address.

4. Company Phone Number *This question is required.

5. Company Address *This question is required.

6. How many testing kits are needed? *This question is required.

7. Preference for testing location: *This question is required.

Space Cell	Yes	Maybe	No
Near Site	Near Site: Yes	Near Site: Maybe	Near Site: No
Off Site	Off Site: Yes	Off Site: Maybe	Off Site: No

8. How many employees do you have? *This question is required.

9. Does your company have any positive COVID-19 employees? *This question is required.

10. Cost of testing and process has been reviewed? *This question is required.

11. Is company able to provide a list of employees for testing with the following: Full Legal Name, Date of Birth, and Home Address? *This question is required.

12. Would you be interested in antibody testing for your employees? *This question is required.

13. Any other questions or concerns?