CLIA-Waived Professional Antigen Testing Application

This is an application to perform Professional CLIA-waived COVID-19 tests through the California Department of Public Health’s CLIA-waived Antigen Program. See all program requirements HERE. As part of this program,

(or their legal guardian or representative)

If using the state's CLIA waiver, results will be sent to participants through an electronic platform.

If using the state's CLIA waiver, the results will automatically report to CalREDIE through an electronic platform.

My organization has previously tested with CDPH's Testing Task Force programs

This includes the At-Home (OTC) Antigen, Professional Antigen or PCR testing programs.

Does your organization primarily serve people under age 18?

e.g., K-12 and preschools, child cares, camps, foster programs

Which of the following categories best describes your organization?

Type of Organization

Select your organization type from the drop down.

COE / District Name

Organization and Contact Information

Organization Name

Organization Address

County

Organization Zip Code

First Name

Last Name

Email Address

Phone Number

What Population(s) will be tested? Please select all that apply.
Note: Only medical providers (MD/DO/RN/NP/Respiratory Care Practitioners) may do professional testing on participants who are unable to self-swab or are ages 0-4 years old.

Participants unable to self-swab for any reason

Participants under age 4

Participants ages 4-11

Participants 12-18 years

Community outreach to general public

Employees /staff

Patients /residents at facility

Other (please specify)

Other Population Tested

How many tests will your organization administer on a weekly basis?

Estimate the total number of tests you will use weekly across all testing locations in your organization. Input cannot be a range.

Have you identified adequate staff and space for testing?

Staff roles include checking-in, swab supervising, testing, reading and communicating the test result, and entering data.
CDPH requires a minimum of 2 staff members per site. We estimate that one person can test 10 participants per hour.

Please provide any additional information about the service(s) your organization provides and how you plan to include COVID-19 antigen testing in your workflow.

Does your organization already have a CLIA?

For more information on CLIA waivers, see https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA. CDPH can provide access to a CLIA waiver for those organizations who do not have their own.

What is your organization's ten character alpha-numeric CLIA number?

Organizations that have their own CLIA numbers must provide their CLIA number and the information of the physician who is providing the standing order for COVID-19 testing. Read more about CDPH's program for sites that have their own CLIAs HERE.

Requisitioning Physician Name

Requisitioning Physician Phone Number

Requisitioning Physician Email Address

Requisitioning Physician NPI Number

Please identify a person at your organization to lead your testing program.

This person should

Be authorized to access Protected Health Information (PHI) data

Have authority to decide which other organization members can access PHI data

Agree to complete the training requirements of the CDPH antigen testing program

Have access to the organization's IT team to help with onboarding to state's IT platform for antigen testing (as needed)

Organization Lead Information

Organization Lead First Name

Organization Lead Last Name

Organization Lead Email

Organization Lead Phone

Please identify a person at your organization to sign the program Memorandum of Understanding (MOU)

This person should be authorized to sign a contract on behalf of the organization and will receive a DocuSign email with the MOU.

MOU Signer Information

MOU Signer First Name

MOU Signer Last Name

MOU Signer Email Address

This is not a production system. Please use this link for the CDPH Testing Task Force.

https://labsupport.powerappsportals.us/testingprograms

CLIA-Waived Professional Antigen Testing Application

Organization and Contact Information

What Population(s) will be tested? Please select all that apply.
Note: Only medical providers (MD/DO/RN/NP/Respiratory Care Practitioners) may do professional testing on participants who are unable to self-swab or are ages 0-4 years old.

Organization Lead Information

Please identify a person at your organization to sign the program Memorandum of Understanding (MOU)

This person should be authorized to sign a contract on behalf of the organization and will receive a DocuSign email with the MOU.

MOU Signer Information

CLIA-Waived Professional Antigen Testing Application

Organization and Contact Information

What Population(s) will be tested? Please select all that apply.Note: Only medical providers (MD/DO/RN/NP/Respiratory Care Practitioners) may do professional testing on participants who are unable to self-swab or are ages 0-4 years old.

Organization Lead Information

Please identify a person at your organization to sign the program Memorandum of Understanding (MOU) This person should be authorized to sign a contract on behalf of the organization and will receive a DocuSign email with the MOU.

MOU Signer Information

What Population(s) will be tested? Please select all that apply.
Note: Only medical providers (MD/DO/RN/NP/Respiratory Care Practitioners) may do professional testing on participants who are unable to self-swab or are ages 0-4 years old.

Please identify a person at your organization to sign the program Memorandum of Understanding (MOU)

This person should be authorized to sign a contract on behalf of the organization and will receive a DocuSign email with the MOU.