STI/HIV/Hepatitis Program

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CBO Testing Supplies Order For...

Welcome to the CBO Supply Ordering Center

CBO Site Order Form

Greetings service providers, please fill out this form to completion. Here are some tips to ensure an efficient ordering process.

Be mindful that supply quantities approved/filled will depend on resource availability.
Please allow 2-4 weeks to receive your order.
Incomplete forms will not be processed.

If you have any questions about your order, please contact Diamond Vines at Diamond.Vines@la.gov

Click "Yes" if you understand and wish to proceed.

Yes

Today's Date

Agency ID

Phone Number

Agency/Facility Name

Days and Hours of Operation

Order Contact

Worker ID/Counselor Number

Agency/Facility Quality Assurance (QA) Coordinator Name

Agency/Facility (QA) Coordinator Email

CLIA Certificate Number

Ship Order To:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Please enter the number of boxes/packets needed.

HIV Test Form- Part 1 (HIV10)

OraQuick Hep-C Kit Control

Determine Kit Control

Syphilis Health Check Rapid Test Kits

OraQuick Hep-C Rapid Test Kits

Determine Rapid Test Kits

INSTI Kit Control

INSTI Rapid Test Kits

Syphilis Kit Control

Have any test kits and/or controls expired since the last order placed for this agency/facility? If the answer is no, then no further action is needed. If the answer is yes, please continue after making your selection.

Yes

Which items have expired? Please indicate the individual quantities that have expired for each item below.