Pre-registration: Ordering no-cost COVID-19 tests for older adults and people with disabilities

The Administration for Community Living and the Administration for Strategic Preparedness and Response are partnering to provide free at-home COVID-19 tests to the aging and disability networks for distribution to older adults and people with disabilities. 
 
To participate, ACL grantees will need to formally register in ASPR's system. Following registration and an onboarding process, you will be able to directly order tests.  This survey is being used to streamline the registration process. 
 
If you are interested in participating, please provide the information below.  Organizations will be contacted in batches to fully register and begin ordering. 
 
What you need to know about ordering:
  • You will received the Siemens CLINITEST® (4-Pack). (The CDC website includes this video explaining how to use this test.) 
  • The minimum order is 800 tests.
  • There is no maximum order; you may order as many tests as you are able to store and distribute in one week. 
  • Tests must be stored away from direct sunlight at 59-77 degrees Farenheit (15-25 degrees Celcius)
  • You will be able to place new orders as frequently as once a week.
  • Only ACL's grantees are eligible to register for this program. However, you MAY share the kits you order with partners, such as your sub-grantees, as long as they also provide services and supports to people with disabilities and older adults (and their families and caregivers). You also may provide the tests to your staff and volunteers.  
 
 
 

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* 1. Organization name

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* 2. Street Address 1

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* 3. Street Address 2 (if applicable)

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* 4. City

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* 5. State (two-letter abbreviation)

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* 6. ZIP code (five-digit)

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* 7. Organization email address (We'll collect the email address for the primary point of contact a little later.  Use this field if your organization has a general email address. You also may use this field to provide the email address for an alternate POC. Otherwise, please leave blank).

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* 8. Organization phone number (xxx-xxx-xxxx) (We'll collect the phone number for the primary point of contact a little later.  Use this field if your organization has a general public phone number. You also may use this field to provide the phone number for an alternate POC. Otherwise, please leave blank).

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* 9. Phone extension (if applicable)

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* 10. Point of Contact - First Name  

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* 11. Point of Contact - Last Name

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* 12. Point of Contact - Email address

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* 13. Point of Contact - Phone number

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* 14. Point of Contact - Phone extension (if applicable) 

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* 15. Are there any special instructions for delivery?

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* 16. Do you have a loading dock?

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* 17. Please select your organization category

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