COVID CSV Submission Registration Form

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)?*

Select or enter value

Please indicate your facility’s status:*

Select

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

Select or enter value

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?

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

Select or enter value

Send me a copy of my responses

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