POCT Needs Assessment form

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We use the Needs Assessment form for sites requesting POCT.
Does anyone have a form they use they could share?
Thanks!
You can email me directly at:
deborah.martuch@hf.org

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If you get any responses from this, can you share? :) 

jentoncray@mhsystem.org 

We have a form!  It's not great, but it works.  I have attached it here.
STL LABPOC Testing Request Form.docx

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