Long Term Care: COVID 19 Testing Status Report [Status or Update to Info Request]
*
1.
Facility Name
(Required.)
2.
Facility State ID Number
(Format: X000000, e.g., N103103)
3.
Facility Address
*
4.
County
(Required.)
*
5.
Name of lab that is either processing your COVID-19 tests or is supplying your facility with COVID-19 tests
(Required.)
*
6.
Are you currently conducting regular testing of staff?
(Required.)
Yes
No
*
7.
I would like to change my testing status to
(Required.)
Testing
Contracted with State Lab, but not testing
Not Testing
Unknown
No Change
8.
I would like to request a non testing status change (e.g., facility name change, facility address change, etc.)
9.
Any other comments or updates for the report?
Current Progress,
0 of 9 answered