COVID 19 Electronic Interface Reporting

Facility Information

* Facility Name

* Address Line 1

Address Line 2

* City

* State

* Zip Code

* Lab CLIA #

* Lab NPI #

* Lab Director

Primary Contact

* Primary Contact Name

* Title

* Email Address

* Phone Number

Secondary Contact

Secondary Contact Name

Title

Email Address

Phone Number

Testing Information

* Volume of KY tests per day

Please estimate if you are unsure of the exact number.

* Type of COVID Testing:

Other