Direct Funding Verification Form

Name of School District or School(Required)

Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

Enter Email Confirm Email

Mailing Address(Required)

Let us know where we should send the reimbursement check.

Street Address Address Line 2 City ZIP Code

Do you currently make COVID-19 testing available to your staff and students?(Required)

Yes

No

Please describe your COVID-19 testing program below.

While the direct purpose of this funding is to support COVID-19 prevention, mitigation, and response, it does support school health services overall. How much did you consider the sustainability of your programming in using this funding?(Required)

I did not consider sustainability at all

I somewhat considered sustainability

I very much considered sustainability

Please share with us any recommendations you have for our program.

Verify Total Reimbursement Request

Staffing

Supplies

Services

Capital Improvement

Other

Total Requested (this will autocalculate)

As of April 15, 2022, we will not send additional funds to your school/district if you have not reported on all the advance funding you received.

Please indicate your preferences for reimbursement.(Required)

I am reporting on expenses made through my advance (no reimbursement requested).

I would like to request a partial reimbursement.

I would like a full reimbursement.

Have you received preapproval for any of the expenses that you are reporting?(Required)

Yes

No

Hidden

If yes, please explain briefly.

Please indicate the amount you would like to receive as a partial reimbursement.

Please share anything else related to your testing program.

Name(Required)

First Last

Date(Required)

I have uploaded backup documentation for each expense for which I am requesting reimbursement for into the sharedrive link provided to my school/district through the Reporting Portal.(Required)

Yes

Signature(Required)

Form Instructions

Direct Funding Verification Form

Verify Total Reimbursement Request