NC DPH ELR Mapping Tool Submission for Review

Please use this form to submit the ELR Mapping Tool to NC DPH for review as part of Steps 3 and 4 of the ELR onboarding process.

Hospital/ Lab Name*

Mapping Contact

Please indicate the name of the person designated to answer any questions that may arise during the review of the mapping.

Mapping Contact Phone

Mapping Contact Email

Mapping Stage*

Please indicate what mapping stage your hospital is submitting.

Select or enter value

Submission #*

Please indicate the number of revisions completed for the current mapping stage. For example, if this is the second submission for Step 3a Reportable Review, enter 2.

Select or enter value

File Attachments*

Please attach the NC DPH ELR Mapping Tool here. To ensure a timely review, the sheet should be completed per the instructions and include a key for any abbreviations. The format we are using for the filenames is: NC ELR For the filename of the next file you submit, please increment the submission #, substitute your initials and change the date to the current date.