OraQuick HIV Grant

Please complete the form below.

Applicant Details

Agreements

Does OraSure Technologies have your permission to use your name, institution/company and project name for marketing purposes in the event your project is selected as a winner?
Yes   No

Are you willing to participate in a presentation (webinar, poster, affinity session) about your program?
Yes   No

Are you willing to provide a short update every three (3) months about the status of your program?
Yes   No

Do you have all the necessary approvals/permissions required to apply for the OraQuick HIV Testing Grant?
Yes   No

Do you agree to the OraQuick HIV Testing Grant program rules and the Terms and Conditions
Yes   No

Distribution Method

  • Direct - OraQuick In-Home HIV Test distributed by public health agencies.
  • Online - OraQuick In-Home HIV Test is ordered by the patient using a redemption code and is delievered via U.S. Post Office from the OraQuick.com website.
  • Retail Access Card - The OraQuick In-Home HIV Test is picked up by patients free of charge at any walgreens or Duane Reade location using a single-use Retail Access Card.

Your preferred method of distribution:
Direct   Online   Retail Access Card   Combination (Please explain in your proposal)

Proposal

Please describe the scope and significance of your project and how does it complement your existing testing program. Include a statement about how you will measure the success of your project and your start/end date. (Limit 500 Characters)

Who is your target population and based on the distribution method you chose, how will you reach them? (Limit 500 Characters)

How many OraQuick In-Home HIV Tests are you proposing to use (maximum quantity: 500)?

What level of funding are you requesting to support your project? (maximum $5,000.000)

How will the grant funds be used? (funding may not be used to purchase test kits; Limit 500 Characters)

If you are using OraQuick Advance HIV 1/2 Antibody Test, please tell us how many you will need.
(Max 200, 0 for None)

How many HIV+ individuals do you expect to identify with your project and how will you ensure that they are linked to care and treatment? (Limit 500 Characters)

Please use this space to tell us anything else about your organization or project that you would like us to know. (Limit 500 Characters)