Long Term Care: COVID 19 Testing Status Report [Status or Update to Info Request]

Question Title

* 1. Facility Name

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* 2. Facility State ID Number
(Format: X000000, e.g., N103103)

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* 3. Facility Address

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* 4. County

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* 5. Name of lab that is either processing your COVID-19 tests or is supplying your facility with COVID-19 tests

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* 6. Are you currently conducting regular testing of staff?

Yes

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* 7. I would like to change my testing status to

Testing

Contracted with State Lab, but not testing

Not Testing

Unknown

No Change

Long Term Care: COVID 19 Testing Status Report [Status or Update to Info Request]

Question Title

* 1. Facility Name

Question Title

* 2. Facility State ID Number
(Format: X000000, e.g., N103103)

Question Title

* 3. Facility Address

Question Title

* 4. County

Question Title

* 5. Name of lab that is either processing your COVID-19 tests or is supplying your facility with COVID-19 tests

Question Title

* 6. Are you currently conducting regular testing of staff?

Question Title

* 7. I would like to change my testing status to

Question Title

* 8. I would like to request a non testing status change (e.g., facility name change, facility address change, etc.)

Question Title

* 9. Any other comments or updates for the report?

Long Term Care: COVID 19 Testing Status Report [Status or Update to Info Request]

Question Title

* 1. Facility Name

Question Title

* 2. Facility State ID Number(Format: X000000, e.g., N103103)

Question Title

* 3. Facility Address

Question Title

* 4. County

Question Title

* 5. Name of lab that is either processing your COVID-19 tests or is supplying your facility with COVID-19 tests

Question Title

* 6. Are you currently conducting regular testing of staff?

Question Title

* 7. I would like to change my testing status to

Question Title

* 8. I would like to request a non testing status change (e.g., facility name change, facility address change, etc.)

Question Title

* 9. Any other comments or updates for the report?

* 2. Facility State ID Number
(Format: X000000, e.g., N103103)