WorkClear Collection Form

Collection Scheduling Form

In order to best assist you, please provide your contact information.

Client Information:

Client/Production name*

Client contact name*

Client contact phone number*

Client contact e-mail address*

Collection Information:

Company Name*

Facility Name

Address*

Unit/Apt/Office Number

City*

Province*

Postal Code*

Date of collection*

Start time for collection*

(Note: Date and Time requested are not guaranteed. Our team will confirm your request by e-mail)

More than one date collection

(Note: for an entire week, multiple weeks, recurring schedule (example, every Thursday))

Please provide more detais*

Please enter a number of collections*

On-site contact name*

On-site contact phone number*

Additional Address 1 of Collection:

Company Name*

Facility Name

Address*

Unit/Apt/Office Number

City*

Province*

Postal Code*

Date of collection*

Start time for collection*

(Note: Date and Time requested are not guaranteed. Our team will confirm your request by e-mail)

More than one date collection

(Note: for an entire week, multiple weeks, recurring schedule (example, every Thursday))

Please provide more detais*

Please enter a number of collections*

On-site contact name*

On-site contact phone number*

Additional Address 2 of Collection:

Company Name*

Facility Name

Address*

Unit/Apt/Office Number

City*

Province*

Postal Code*

Date of collection*

Start time for collection*

(Note: Date and Time requested are not guaranteed. Our team will confirm your request by e-mail)

More than one date collection

(Note: for an entire week, multiple weeks, recurring schedule (example, every Thursday))

Please provide more detais*

Please enter a number of collections*

On-site contact name*

On-site contact phone number*

Collect Multiple locations Remove additional address

(Note: You can add 2 additional addresses of locations)

Number of collections*

I acknowledge that changes to the expected volume of collections, greater than 10% of the original estimate, should be communicated to LifeLabs a minimum of 2 business days before the collection date. I also acknowledge collection services are subject to availability, even with a minimum of 2 business days’ notice

On-site information:

On-site materials provided by the Client*

*The materials below are required for each collector. Example: if you have 50 people needing to be swabbed, LifeLabs will provide 2 collectors. Therefore, 2 of everything below will be required. a. 1 table and 2 chairs b. Garbage bin c. Facial tissues for donors d. Sanitizing wipes e. Hand sanitizer f. Pens

I acknowledge all of the above will be provided by the Client and will be available on-site on the day of collection.

A fridge will be available to store collected swabs

I acknowledge the on-site contact person will be available to receive supplies prior to the scheduled collection date.

Will the supplies be delivered to the same address as above and to the attention of the same on-site contact person as above?

Yes No

Is this address residential or commercial?*

Address for supply delivery*

On-site contact name for supply delivery*

On-site contact phone number for supply delivery*

I acknowledge the location for collection is a well-ventilated space with temperature control and enough space for appropriate social distancing (ex: 6ft between each collector).

I acknowledge additional charges may apply if any changes are made within 48 hours of the scheduled date.