PPE & Rapid COVID Test Request Form

SUPPLY REQUEST
for
Personal Protective Equipment &
Rapid COVID-19 Test Kits

This portal can be used to order PPE and rapid antigen test kits from the Larimer County Department of Health and Environment (LCDHE). The Department will review each order and can deny, alter, or delay any order without notification. Approved orders are fulfilled during the normal work week (Monday - Friday).

Supply requests are considered on the basis of urgency (nature of an emergent request), the availability of products, and whether or not the requesting agency has exhausted available options to obtain supplies. Please be advised there is no guarantee on fulfillment of orders or the timeline resources will be allocated.

The requesting agency must pick-up supplies at a location to be determined once the application has been approved. Supplies cannot be shipped.

Requesting Agency Must Complete This Form

(Form posted to: https://www.larimer.gov/health/emergency-preparedness-and-response)
ABOUT YOU

Point-of-Contact
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
E-mail*
example@example.com
Requesting Agency
Organization Name*
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Staff:*
Number of Clients/Residents/Attendees:*
Organization Type*
If "Other" selected, please describe: *

COVID-19 TEST REQUEST
COVID-19 Antigen Test Kits (Note: Each kit contains 2 tests):

Self-administer rapid antigen test kits
Quantity of self-administer rapid antigen test kits:
Quantity of Point-of-Care rapid antigen test kits: *