COVID CSV Submission Registration Form

If you have not already registered with DSHS to submit COVID-19 laboratory results electronically, please complete the questions below. If you are unsure whether you are registered please send an email to COVID-19ELR@dshs.texas.gov to verify. After you submit a completed survey for your facility, you will be contacted within 3-5 business days and receive further instruction on next steps.

Please note that fields marked with an asterisk * must be completed.

Facility Information

Are you registering your intent with DSHS to initiate electronic laboratory reporting of COVID-19 (SARS-CoV-2)?

Please indicate your facility’s status:

What type of COVID-19 test data will your facility submit?

Legal Business Name of Reporting Facility:

CLIA Number of Reporting Facility:

Address of Reporting Facility

City of Reporting Facility

State of Reporting Facility

ZIP of Reporting Facility

Contact Information

Primary Contact Name

The primary contact here should be the programmatic or administrative lead. This individual will be contacted if there are questions concerning the facility at large.

Primary Contact Title

Primary Contact Phone

Phone

Primary Contact Phone Extension

If not applicable, type N/A

Primary Contact E-mail Address

Secondary Contact Name

Secondary Contact Phone

Phone

Secondary Contact E-mail Address

Secondary Contact Phone Extension

If not applicable, type N/A.

System Information

Name of the sFTP client your facility uses:

Number of reporting facilities that will be included in this interface:

Name of EHR Software used to report data

Vendor Name

Product Name

Product Version

Most frequently reported tests performed at the reporting facility (separate by a comma):

If you are a new submitter, do you want to submit via HL7, CSV format, or SimpleReport?

If you want to submit via HL7, can your system create HL7 version 2.5.1 messages?

Send me a copy of my responses

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