Registration Form for Reporting COVID-19 (SARS-CoV-2) Lab Testing Data in Texas Who should complete this registration form? All laboratories (commercial, hospital, public, or non-traditional testing facilities) who are performing tests for COVID-19 (SARS-CoV-2) in their lab facility must register. 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 the below registration form for your facility, you will be contacted within 3-5 business days and receive further instructions on next steps. Registration Form All fields marked with an asterisk (*) must be completed. Submitter Status & Agreement 1. Are you registering your intent with DSHS to initiate electronic laboratory reporting of COVID-19 (SARS-CoV-2)?* Yes No 2. Please indicate your facility’s status:* New submitter to DSHS (not currently submitting lab data in HL7 format) Currently submitting HL7 format lab data to DSHS 3. What type of COVID-19 test data will your facility submit?* Molecular testing (including PCR or isothermal technology) Antibody testing Antigen testing At least two or more of the tests listed above Other Enter other… If you selected "Other" above, please specify the type of COVID-19 test data your facility will be submitting 4. I understand that ALL COVID-19 (SARS-CoV-2) lab results must be submitted including positive, negative, and indeterminate results.* Facility Information 5. Legal Business Name of Reporting Facility:* 6. CLIA Number of Reporting Facility:* 7. Address of Reporting Facility Street Address City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP 8. Primary Contact 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 Name:* Primary Contact Title:* Phone Number (with area code):* Extension: E-mail:* 9. Secondary Contact The secondary contact should be the technical lead who will conduct all the technical aspects of the onboarding and reporting process. This person will be contacted if there are issues in data reporting. Secondary Contact Name:* Secondary Contact Title:* Phone Number (with area code):* Extension: E-mail:* Interface Details 10. Name of the sFTP client your facility uses: 11. Number of reporting facilities that will be included in this interface: (DSHS will contact the Primary Contact at your facility for additional information, which will include the name and CLIA number of all additional facilities.) 12. EHR Software Name of EHR software used to report data: Vendor Name: Product Name: Software Version: 13. Most frequently reported tests performed at the reporting facility (separate by a comma): 14. If your facility is sending specimens to a reference laboratory for COVID-19 testing, you should verify that those test results are being submitted to DSHS. If you are utilizing a reference lab, have you verified this? Yes No N/A 15. If you are a new submitter, do you want to submit via HL7 format, CSV format, or SimpleReport? (If you are a current submitter, select N/A.) HL7 format CSV format SimpleReport N/A 16. If you want to submit via HL7, can your system create HL7 version 2.5.1 messages? Yes No N/A CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question 1 + 0 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4. Submit Leave this field blank Book traversal links for Registration Form for Reporting COVID-19 (SARS-CoV-2) Lab Testing Data in Texas ‹ Information for Laboratories Up Complying with Governor’s Order to Report COVID-19 Lab Test Results in Texas › COVID-19 (Coronavirus Disease 2019) COVID-19 (Coronavirus Disease 2019) Information for Laboratories Registration Form for Reporting COVID-19 (SARS-CoV-2) Lab Testing Data in Texas Complying with Governor’s Order to Report COVID-19 Lab Test Results in Texas NEDSS COVID-19 Laboratory Submitter Resources