Pennsylvania Department of Health

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PA-ELR Laboratory Registration Form

Directions for completing form:

Provide all information and answers to the questions. Note: incomplete forms will not be processed.
Questions please contact the Help Desk at (717)783-9171.

Please note that completing this registration form is the first step of the process to gain access to PA-NEDSS and PA-ELR. Once you have completed and submitted this form you will be contacted by the PA-NEDSS Team to continue the process. You will not be automatically granted access to PA-NEDSS and PA-ELR by completing this form only.

Organization Name:

CLIA ID:

1. Which Laboratory Information System (LIS) is currently being used at your organization?
MISYS
CERNER
SIEMENS
Other (Please Specify)

2. Which type(s) of Disease Reporting Codes does your system utilize? (check all that apply)
LOINC
SNOMED
Other (Please Specify)

3. Which exportable data format(s) can your LIS generate? (check all that apply)
HL7 v2.3
HL7 v2.3.1
Comma Delimited
Other (Please Specify)

4. Does your organization currently report electronically to the PA Department of Health? (check all that apply)
NO
YES, via online data entry to PA-NEDSS
YES, Infectious Disease
YES, STD
YES, to HIV program
YES, Lead
YES, Cancer Registry
YES, other (Please Specify)

5. Please indicate in the table below the type of test(s) and estimated volume(s) your organization will report through PA-ELR (Note: HIV & Cancer will not be initially accepted into PA-ELR)

Type of Tests	Estimated Number of Test Results
Infectious Diseases		Per
STD		Per
Lead		Per
HIV		Per
Cancer		Per
Other		Per
If "Other" please specify

6. What operating system does the computer that will be sending ELR data to the PA Department of Health run under?
Windows XP
Windows 2000
Windows NT
Unix/Linux
Other (Please Specify)

LABORATORY CONTACT INFORMATION

Lab Contact Name :

Lab Contact Title :

Lab Contact Phone:

Lab Contact Email:

ORGANIZATION'S INFORMATION TECHNOLOGY CONTACT INFORMATION

IT Contact Name :

IT Contact Title :

IT Contact Phone:

IT Contact Email:

ORGANIZATION'S MAILING ADDRESS

Address :

City : State: Zip: