Rural Test & Trace Toolkit: RT3

Rationale for Community Action & the Vashon Island Strategy

Rural COVID Testing - IdentificationRural and tribal communities are at substantial risk from the COVID-19 pandemic caused by the coronavirus SARS-CoV2 pandemic (CNN, NYTimes, Vox). Several factors contribute to this risk, including a paucity of acute care resources, long drive times to access care, an aging population often with complicating health issues, and multi-generational homes with a higher proportion of essential workers when compared with urban centers (Politico).  Geographical isolation may delay the arrival of COVID-19 in rural vs urban areas, but that isolation has thus far been associated with even greater delays in essential responses- social distancing measures and testing for the virus followed by vigorous contact tracing.

Vashon is a rural island community of 11,000 located in Puget Sound near Seattle, WA.  We have no acute care or hospital care. When faced with these challenges, we developed and deployed a testing strategy that allowed our community to launch a successful testing site in less than 3 weeks using local resources, a volunteer workforce and without resources from our county’s public health system that was already stretched thin. We believe that by following our blueprint, rural and tribal communities could stand up similar testing in one week using volunteer or professional medical and non-medical staff.

Our strategy is founded on three basic principles: 1) that informed patients can self-collect nasal swab specimens for testing; 2) that exposure of volunteer healthcare workers to SARS-CoV2 must be minimized; and 3) PPE use can be minimized during testing by isolating patients and workers from each other throughout the testing process.

RT3 - Rural Covid Testing, Administrative Center The most important element of this strategy is the reliance on patients to swab their own noses by following clearly written instructions delivered before they come to the test site and immediately before swabbing their noses. This method was pioneered by the Seattle Flu Study, the SCAN project and a recent 500-patient prospective study comparing side-by-side self-collected anterior nares (nasal) to medical technician-collected nasopharyngeal (NP) swabs. This study demonstrated 94% sensitivity of the nasal swab strategy, leading to FDA approval of this method on March 23, 2020. In a recent opinion piece, Bill Gates listed self-collected nasal swab collection of COVID-19 specimens as the 1st of five innovations essential for reopening of the US economy.

Healthcare workers are at particular risk of contracting COVID-19 because of close and repeated contact with patients that may be infectious.  This is especially true during acquisition of nasopharyngeal samples which often induces sneezing that may aerosolize the virus.  In rural and tribal communities staffing of clinics is often limited in the best of times: limiting healthcare workers exposure is essential. Our drive-through testing strategy is designed to minimize exposure of workers to patients and patients to workers.  By having patients self-collect specimens in their car, we are able to maintain a safe distance between patients and workers while still observing the swabbing process and being available if/when problems arise.  This process also minimizes PPE required to keep medical and non-medical workers safe.

Creating a Community COVID-19 Testing Site

Set up a Steering Committee

A committee of 5 or 6 people is needed that bring a range of expertise including medical professionals (infectious diseases if available), a clinic manager or someone with program management experience and someone who can organize logistics support including IT. The group should quickly choose a leader who can represent the project in discussions with other emergency management organizations. This effort requires a major time commitment- the group will need to meet daily at first and work together collaboratively, potentially for months. An advisory committee (infectious disease, public health, local clinicians) will improve decision-making, networking, and chain-of-command reporting, while reducing time commitments for rural clinicians and public health officials already over-burdened by the pandemic.

Work with the Incident Command Team Coordinating the COVID-19 Response (local, county, state, federal)

Mediccal Reserve Corps logoThe COVID-19 epidemic has put the US public health system under enormous strain, a fact that is exacerbated by chronic under-funding.  Worldwide travel patterns introduced the novel Caronavirus into urban areas where high population densities helped it to spread.  As a result, most public health efforts have so far been concentrated in cities. We believe that rural communities can and should accept responsibility for protecting their communities now.  We suggest engaging and marshaling local resources while communicating your intentions upward. If your community or area has a Medical Reserve Corp (MRC), begin by talking to them- they may already be organizing. If your community has a disaster preparedness organization talk to them- they will have an Incident Command Team.  Your Testing and Tracing site will become an integral part of your community’s response to the pandemic, and must necessarily integrate into your community’s incident response structure.  The Vashon MRC is housed within a 501(c)(3) disaster preparedness organization (VashonBePrepared) that provides logistics, communications and fund raising support for the MRC testing effort in addition to many other community support activities.

I just finished the Test and wanted to thank you all for a job so well done. Superb planning, friendly helpers, you all made it work like clockwork! Thank you!”

You should quickly let your county or state public health department know what you want to do. They may be able to help with resources and are likely to be supportive of your activities because it relieves them of the burden of providing COVID-19 testing in your community. They may or may not be supportive of patient self-collection of samples, but you have an opportunity to educate them about this FDA approved method. Explain its larger benefits.

Test Site and Logistics

Rural_COVID_TestingA generic site map is available. Our test site is located at a historical home on public land that has a modest sized parking area adjacent to a semicircular drive. Desktop computers, sampling materials, PPE, and test site supplies are set up and stored in the home's garage. There is ready access to lavatory and separate hand-washing facilities.Flow through the site is as follows:

  1. Patients stop at one end of the drive and are met by the Greeter. Patients show their ID through a closed car window and the Greeter confirms their appointment.
  2. A Runner brings sampling materials and instructions contained in a disposable paper bag, and places them on a table to which the patient is directed once the Runner has moved away.
  3. The patient stops and picks up the bag, and is then directed by the Runner to a parking space.
  4. The patient reviews instructions and swabs their nose under supervision by a Medical Observer who is wearing PPE. Patient then places sample vial in biohazard bag that also contains a lab requisition in an exterior sleeve.
  5. Patient is directed to the drop off point and deposits their sample in a cooler containing frozen ice packs. Patient then leaves the site.
  6. At the end of the day, the contents of the cooler are double bagged by the medical volunteer in PPE for courier pick-up.  Usually a single set of gown, gloves, mask and eye protection are needed per 4-hour shift.

While the test site needs are simple, there is a requirement for lots of things that are essential but are also relatively easy to find in most communities. A complete list can be found here.

The Test Site Workforce

Rural COVID Testing - GreetingThe testing strategy we use could be carried out in association with an established clinic or could operate independently staffed entirely by volunteer healthcare and other workers.  The process is straight forward enough that any motivated organization could set this up in collaboration with a clinic or volunteer medical organization.

Our site operates with a staff of 2 non-medical and 2 medical volunteers.  Non-medical personnel carry out Greeter and Runner functions. Our runner also directs cars from pick-up to parking and parking to drop-off locations. One medical volunteer in PPE is the test observer and is responsible for collecting and preparing samples for shipping at the end of the testing day. A second medical volunteer manages the schedule in real time and has responsibility for assembling sampling materials & instructions.  As we have gained experience, we can operate the site with 2 non-medical volunteers (the Runner also observes drop off) and 1 medical volunteer (if new patients are not added during testing hours).

Our efforts to minimize exposure of workers has been critical to recruitment efforts, as was training of volunteers before the site opened to minimize exposures and understand appropriate use of PPE.

COVID-19 Testing Strategy

Sampling by Self-Collected Nasal Swab

Rural COVID Testing - SwabIt is important that patients understand the importance of careful collection of the nasal specimen. It isn’t complicated, but we believe it is important to use instructions that have been proven to work. For this reason, we provide the same written patient instructions (with permission) that were used in the Everett WA study. We reinforce the importance of reading and following the instructions exactly during a pre-test conversation during which the test is scheduled.

Who to Test for COVID-19

Current guidelines in WA and across the nation, limit testing to symptomatic patients with a healthcare provider’s order.  Initially, testing was limited to those at high risk from COVID-19 due to age or other risk factors (diabetes, lung, heart or kidney disease, immunodeficiency and pregnancy).  As testing has become more available, guidelines have been relaxed so that testing of anyone with symptoms of fever, upper or lower respiratory complaint or body aches and chills is now warranted. It is likely that testing criteria will change, so it is wise to check the FDA and CDC COVID-19 websites frequently for new information.

We facilitate provider orders by including an order form on our COVID-19 testing website. However, ~10% of our patients do not have a primary care provider. In that circumstance, Vashon MRC health providers screen patients and decide whether a test is warranted. It is essential when providing this service to clearly communicate whether or not you can provide management of tested patients’ symptoms. We do not have that capability (we’re not a clinic), so we provide web links and phone numbers for low cost clinics in our area.

Personal Protective Equipment

RT3 - Rural Covid Testing - CERT at the Ready, by Patricia Toovey Our non-medical workers wear disposable or cloth masks as suggested by our local health department for all people when in public. We provide gloves if workers want to wear them. It should be emphasized during training that if gloves are worn, hands should still be washed regularly- a contaminated glove is just as effective in spreading COVID-19 as a naked hand. 

One medical worker who supervises patient self-collection of nasal specimens wears an N95 mask and has ready access to a gown gloves and face shield on the rare occasion that they are needed to help a patient with the test.  This worker does not need to change PPE during a shift unless they come in close contact with a patient. At the close of the testing day this worker collects samples and prepares them for shipping before disposing gown and gloves. N95 masks are reused.  A 2nd medical worker mans a computer station and does not require PPE beyond a cloth or disposable mask.

Vashon's RT3 Rural COVID Test SIteSocial distancing is practiced by all test-site workers.  This is most challenging in the enclosed space we use for scheduling and materials storage during preparation of sampling bags before the testing day begins and during computer training of individuals learning our scheduling system. 

Testing Laboratory

The acquisition of sampling materials and selection of a diagnostic lab to perform the RT-PCR test is critical.  We chose LabCorp because they could supply us with sampling materials, already provided courier service to our rural community, had the lowest price we could find, are willing to bill patients’ insurance, and return results through a convenient web interface in 48-72 hours. Their service has been generally very good.  If a commercial laboratory already services a local hospital or clinic and provides COVID-19 RT-PCR testing, that may be the easiest way to get up and running quickly.

Below is a list of large commercial clinical diagnostic laboratories that can perform molecular diagnostic testing on nasal specimens with contact information, list price and unverified turnaround times.  You may be able to negotiate a better price than the list price by calling and negotiating, particularly if you anticipate large number of tests.


Contact information

List price/test


Sampling supplies


800 598-3345


2-3 days



866 697-8378


2 days


MicrogenDX (Texas)


Specialty Labs (Louisiana)

Capstone Diagnostics


Express Labs




MHS Labs



Lehigh Valley Genomics



CRL (Kansas)


Mayo Clinical Lab. (Minnesota)

Exact Sciences (Wisconsin)

Northwestern School of Med


You should also talk to your local health department about testing supplies. If you are able to locate your own sampling materials-synthetic swabs (no cotton, wood shafts or Ca-Alginate) and transport medium) you will have a larger choice of clinical laboratories.

Tracking Samples and Results

Rural COVID Testing - Sample CollectionIf you are a clinic or working with a clinic you probably have access to an electronic medical record and scheduling tools. This is a major advantage because these tools are generally more user friendly than the scheduling process we use and they will already be HIPAA compliant.

Because VashonBePrepared's MRC COVID Testing Project is not associated with a clinic, we put together a spreadsheet-based system for tracking samples and patient contacts. We found it most convenient to use the G-Suite of tools because they are sufficiently secure to allow HIPAA compliance. The system is comprised of several components.

First the website we provide in the Toolkit contains a web submission form that providers can use to submit orders. The output of this submission is a g-sheet containing provider and patient contact information. This is how most orders come to us.

As orders arrive, we first check that the provider’s NPI number is valid as a control against patients ordering tests.  This has not been a problem.  We then call the patient to collect demographic, contact and insurance information. This information is entered in a Patient Information Form that serves as a requisition for the diagnostic lab.  We also ask about common COVID-19 symptoms so that appropriate ICD-10 codes can be included.

We then ask the patient when they would like to come to be tested and transfer patient and provider information into a Patient Schedule G-sheet. Each patient visit is assigned a unique identifier so we don’t have to use their name at the testing site. This number consists of Date-Time-Lane:  e.g. 421-1300-1 is a time slot on April 21 at 1pm. The lane number allows the schedule to be double or triple booked if testing is parallelized to increase capacity.  Anyone with access to the scheduling G-sheet can modify it, so most of our scheduling is done from the scheduler’s home. A confirmation of test time is emailed to the patient along with driving instructions to the site, a description of site logistics, instructions for nasal swabbing and a “What you need to know” document.

Finally, after the test day is complete, patient and provider information are copied onto a Master Patient List that allows us to manage reporting of test results to providers and patients.  This master list is downloaded to an external storage device nightly to provide a secure backup of all tests performed and their status.

Test Reporting and Contact Tracing

WRT3 - Rural Covid Testing - We Love Signs, by Patricia TooveyResults should be returned in less than 72 hours and should be reported back to providers and patients quickly.  We check for results on the LabCorp information system (and update the Patient Master List) several times a day.  We use the LabCorp system to email or fax patient results directly from their system.  Some labs may already have this set up for the clinics and providers they serve, so check with them.

We believe it is important to speak with patients whether their result is positive or negative and have developed scripts for reporting of both positive and negative results to patients. The focus of the discussion with positive patients is reinforcing the importance of isolation, identification of needed support services and identifying potential contacts.  The focus of discussion with negative patients is the possibility of a false negative result and the need for continued isolation for a total of 14 days from the onset of symptoms or until symptoms have been gone for at least 72 hours, whichever is longer.  We recognize this is a conservative recommendation, but believe it is warranted because we do not know with certainty what the true false negative rate of nasal or nasopharyngeal swabbing is.

You should contact your county or state public health department to understand what support they can provide for contact tracing. They are likely to be glad for the help!  Contact tracing is just beginning in King County after 6 weeks in which there was too much disease to be able to do it effectively. We are working with our local health authorities to develop the precise mechanism and scripting for this activity. This site will be updated with scripting and further advice when it becomes available.

Public Outreach and Information

Webpage Template

Webpage Template from EOC OnlineA concise webpage is the quickest way to communicate information about your testing activity to your community. We provide generic content that describes the testing strategy and related information. This sample webpage is available for your use in three formats:

  • Bare HTML, with no external dependencies
  • Simple styling, using Bootstrap4, jQuery, jQueryUI, and Google Fonts open source libraries
  • Fancier styling, with images and Fontawesome that can serve as a standalone website, perhaps as a subdomain to your own site.

These can be downloaded and modified as desired from Limited support is available through, or by filing an issue on GitHub.

Legal Considerations

HIPAA Requirements Need to be Met

It is important that patients’ protected health information (PHI) is handled in a HIPAA compliant fashion. This means ensuring your information system conforms and that people who have access to PHI treat it appropriately.  Training of volunteers is advised. Several common errors to be avoided are:

  • Storing PHI on your personal computer
  • Not signing out of your information system when work is done
  • Sending PHI through unencrypted email servers
  • Leaving a message on a patient’s answering machine without prior approval
  •  Delivering PHI to incorrect fax numbers, email addresses or phone numbers.

If you plan to have providers submit orders from your website, be sure to use https rather than http. This level of security is required for HIPAA compliance.

Liability Protection from States, CARES Act Coverage

Most states provide liability protection in the form of immunity for volunteer healthcare workers responding to a declared emergency. Moreover, the CARES act (SEC 4216), passed in response to the COVID-19 emergency, provides that volunteer healthcare professionals engaged in the emergency response to COVID-19 “shall not be liable under Federal or State Law for any harm caused by an act or omission of the professional in the provision of health care services during the public health emergency declared by the Secretary of Health and Human Services.”

We recommend that anyone standing up a testing site consider obtaining legal advice to understand the limits of this and any other liability coverage.

Who We Are

The Vashon COVID-19 Testing Project Steering Committee

Rural COVID TestingJim Bristow, MD (Chair) is a semi-retired physician-scientist living on Vashon Island. He is a graduate of Harvard Medical School and was a practicing pediatric cardiologist at UCSF until retirement in 2015. From 2004-2015 he served as Deputy Director of the Department of Energy’s Joint Genome Institute and is currently a senior advisor to the Biosciences Area at Lawrence Berkeley National Laboratory. He is a new recruit to the Vashon MRC.

Zach Miller, MD is a graduate of Columbia University College of Physicians and Surgeons. He did post graduate training in Pediatrics at Stanford and Infectious Diseases at Children's Hospital in Seattle. From 1977 to 2015 he worked as an Infectious Diseases specialist at Group Health/Kaiser where he pioneered home antibiotic treatment and other patient self-care strategies. He served on the Group Health Permanente Medical Group Board of Directors until his retirement in 2015.

Ina Oppliger, MD is a board certified rheumatologist. She completed medical school and internal medicine residency at the University of Kansas, followed by a fellowship in Rheumatology at the University of Washington. She was a clinical associate professor at the University of Washington and staff physician at Group Health Permanente, Medical Group where she served on the Board of Directors. She is the co-director of the Vashon MRC and a Pierce County MRC volunteer for the past 2 years.

Bonny S Olney, DO received her degree from The University of North Texas Health Science Center and trained in Family Practice at the University of Texas Health Science Center, Houston followed by 20 years in independent family practice. She worked as an IPA medical director for 2 years helping independent physicians navigate value-based care and helped launch a Medicare Accountable Care Organization. She currently works as a Physician Advisor and Team Lead for a revenue cycle management company providing support for acute care hospitalization claims.

Clayton J Olney, DO was a PA and EMT practicing in a Houston suburb for two years prior to medical school. His DO degree was conferred in 1993 and he completed Pediatric residency and a Neonatal fellowship at the University of Texas Health Science Center, Houston. He has more than 20 years’ experience in neonatal medicine with concomitant medical staff leadership experience in Houston, Dallas and Tacoma. In 2017 he accepted a civilian neonatal appointment that includes training pediatric residents at Madigan Army Medical Center.

Lydia Aguilar-Kirschner, MD earned her medical degree at UNAM in Mexico City, where she did field work in type 2 diabetes and lactose intolerance in populations around Mexico City. She earned a PhD in Genetic Epidemiology doing work on type 2 diabetes studying the Mexican-American population in the Rio Grande Valley. She recently retired after working on the basic research of insulin release for almost 4 decades. She is bilingual and has played a major role in medical outreach to the latinx community on Vashon Island.

Shawn Boeser has worked in international humanitarian emergency response for 16 years, primarily with the United Nations and as a freelance advisor. In 2018-19, she worked for the UK government Department for International Development (DFID) in Uganda on Ebola prevention and preparedness. She currently works as an Operations Manager for a small technology company based in Washington State. She volunteers on the Vashon Island Emergency Operations Team.

External Advisors

Jay Shendure is the Scientific Director of the Brotman Baty Institute and a Howard Hughes Medical Investigator and Professor of Genome Sciences at the University of Washington School of Medicine. His research interests include genomic technologies and their application to human health and disease. He is a principal investigator of the Seattle Flu Study and currently co-leads the Seattle Coronavirus Assessment Network (SCAN).

John Sirois is a citizen of the Confederated Tribes of the Colville Reservation, John (say’ay’) served much of his 20-year career within the Colville Tribes’ government in Cultural Preservation and Renewable Energy and later as Council Chairman and Member. At UCUT, John facilitates the collaborative intertribal committee process that establishes a strong policy position for the Upper Columbia Untied Tribes. Though John earned a B.A. in history from Dartmouth College and a Master of Public Administration from the University of Washington, he feels especially fortunate to have learned traditional ways from his tribal ancestors and elders.

Tootie Tatum has roots in rural Texas and received her PhD from the University of New Mexico. After working on the Human Genome Project at Baylor College of Medicine, Tootie founded the Clinical Molecular Diagnostics Laboratory at Texas Tech School of Medicine and the commercial laboratory that is now MicroGenDx. In 2011 she joined Lawrence Berkeley National Laboratory's Joint Genome Institute where she led the management of high-throughput DNA sequencing projects. In 2014, she received an MBA from UC Berkeley and founded Blackhawk Genomics to assist companies entering the genetic testing market. She directs CLIA clinical genetics laboratories across the United States.

Eric Walker has more than 30 years of experience in leadership, financial and operations management, institutional capacity building, and systems development in international non-governmental organizations (NGO). He has served on executive teams of multiple international NGOs working across the international development sector, including his long-term role as finance and operations leader of the Seattle-based global health NGO PATH.

Dr. Bristow's MSNBC Interview

MSNBC Live with Hallie Jackson: May 20, 2020 interview with Ayman Mohyeldin and Dr. James Bristow on Vashon Medical Reserve Corps RT3 Toolkit

About this Site

Medical Reserve Corps logoThe Vashon Island Medical Reserve Corps and VashonBePrepared are making the information and documents on this website freely available with the hope of stimulating local action in rural and tribal America to combat the SARS-CoV2 epidemic. This is currently a beta version of content and documents- we welcome your questions and feedback which you can provide at:

Please feel free to tell others about this site and our work, but we ask that you direct others to our site to obtain documents so that we can keep track of who is using these materials

Guide to RT3 Downloadable Documents

Download zip file of all the following documents.

  1. Test site instructions: This is a PowerPoint drawing of our current site and instructions that we email to patients with nasal swab instructions at the time we schedule them. It can be modified to fit your site and process in PowerPoint.
  2. Nasal swab instructions: This is a Word document that describes our process which is based on that used in the Everett, WA study upon which FDA approval was given. You should replace our photos with ones of your swabs and vials which will vary depending on the laboratory you’re using. This document is emailed to patients before testing and provided with sampling materials at the test site.
  3. What to do after your test: This is a Word document that is sent with Test site and Nasal swab instructions before the test. It describes the need to quarantine while patient’s test is pending.  It also describes false negative risk.
  4. Test site logistics: This is a Word document that lists the property needs of the site.
  5. Patient schedule: This is an Excel file that can be used as is, or can uploaded into Google Suite of tools. We find G Suite effectively allows multiple people to view or modify the document without having to worry about multiple versions. To upload to G Drive, open Gmail, click on the nine arrayed dots at the upper right of the window and click on the triangular Drive icon. Then My Drive>upload files and choose the files you wish to upload from your desktop. Patient information should be kept only in G Suite (NOT on your desktop) to be HIPAA compliant

    The columns are organized so that data can be cut and pasted directly into the Master Patient List (see below).

  6. Patient information form: This is a fillable form created in Word that we use as a requisition.
    1. The form can be modified in Word, but one must first add the Developer tools to the tool bar.
    2. -To do this on a Mac, click on Word>Preferences, then Ribbon & Toolbar and finally check the Developer box under Custom Tools.
    3. -To do this on a PC, go to the File tab, go to Options > Customize Ribbon. Then under Main Tabs, select the Developer check box.
    4. To modify the text, click the Developer tab and click on the Protect Form icon. This is a toggle that will turn on and off the ability to modify the form. When the form is protected, the Developer icons are greyed out and the form is fillable in Word. When the form is not protected, the Developer icons allow text modification and insertion of check boxes and dropdown menus.
  7. Pretest template for gmail: This is a brief note that we send to patients when they have been scheduled for a test. This can be made into a reusable template by opening gmail, clicking Compose and pasting/entering this or any desired text into the message area.  Then click on the 3 vertical dots to the left of the trach can at the bottom right of the message, then Templates>Save Draft>Save as new template.  The saved message will become an option in the Templates menu. We attach driving instructions, site instructions, nasal swab instructions and “What to do after your test” guidance to this email.
  8. Master Patient List: This an Excel file that contains all patients we have tested and all their and their providers non-insurance information.  It can be loaded onto Drive as described for the “Patient Schedule” spreadsheet.  Patient data can be copied and pasted into the Master Patient List from the Patient Schedule document. We do this at the end of each testing day. We use this document to manage test status and reporting results to both patients and providers.  As with the scheduling document, having this file in G Suite allows several people to be working from the list at the same time without confusion.
  9. Script for Negative Test: This is a fillable Word form that we use to discuss continued self-isolation for patients with symptoms that test negative. It contains the Vashon MRC’s recommendation which is more conservative than WA state’s or our county’s.  To modify the script, you must first enable the Developer tools as described above for #6, Patient Information Form. 
  10. Script for Positive Test: This is a fillable Word form that we use to discuss self-isolation for patients that test positive, to discuss quarantine for household contacts and collect information about other contacts for use in contact tracing.   Both household and non-household contacts that are collected are transferred to a master list used by those calling contacts so that the identity of the index patient can be protected.  To modify this script, you must first enable the Developer tools as described above for #6, Patient Information Form.

If you are having trouble accessing any of these files or have feedback about the documents please email us

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