KYCOVID19 Testing Location Survey

Location Information

Please complete an individual submission for every testing location or type.

TESTING LOCATION

* Facility name:

* Facility phone number:

Enter number for appointment scheduling.

* Address 1:

Address 2:

* City:

* State:

* Zip code:

* County:

CONTACT INFORMATION (for internal use only)

* Contact first name:

* Contact last name:

* Contact phone number:

Ex: 111-111-1111

* Contact e-mail: