Pennsylvania Syndromic Surveillance Registration Form

Directions for completing form:
  1. Provide answers to all questions. Incomplete forms will not be processed.
  2. For questions regarding this form, please email RA-DHMU.SYNDROMIC@pa.gov.
Please note: Completing this form will only register your intent to submit syndromic surveillance data. The Department of Health cannot bring all organizations in Pennsylvania into the syndromic surveillance system at this time. Registrants will be prioritized based on type of organization, geographic location, and number of anticipated reports. If your organization is selected to begin onboarding or be put into the onboarding queue, you will be contacted by the Department of Health or its syndromic surveillance system vendor to continue the process.


SECTION 1: ORGANIZATIONAL INFORMATION


ORGANIZATION'S MAILING ADDRESS

Organization Name:

Address Line 1:

Address Line 2:

City : State: Zip:

Phone Number:


NPI:


ORGANIZATION CONTACT INFORMATION

Organization Contact Name :

Organization Contact Title :

Organization Contact Phone:

Organization Contact Email:


ORGANIZATION'S INFORMATION TECHNOLOGY CONTACT INFORMATION

IT Contact Name :

IT Contact Title :

IT Contact Phone:

IT Contact Email:

Please characterize your organization/practice (check all that apply):
Hospital with an emergency department
Other type of inpatient facility
Primary care - family practice
Primary care - pediatrics
Primary care - internal medicine
Other ambulatory care practice (please specify)

Please indicate the estimated number of messages (basically patient visits) your organization will report to syndromic surveillance:

Per

Which exportable data format(s) can your System generate? (check all that apply)
HL7 v2.3.1
HL7 v2.5.1
Comma Delimited

Is your organization onboarding to meet Meaningful Use requirements?
Yes No

If you answered yes, please complete the Meaningful Use below. Otherwise proceed to submission.


Section 2: Meaningful Use

  1. If your facility is onboarding for the purposes of Meaningful Use, this section must be completed.
  2. The expectation of the Pennsylvania Department of Health is that regardless of the Meaningful Use stage to which an organization is attesting, once the onboarding process starts, the organization will commit to working toward ongoing submission.

Is your organization currently submitting or planning to submit syndromic messages through an HIE?
Yes No

Is your organization currently submitting syndromic messages in a non-Meaningful Use-compliant format?
Yes No

Which Meaningful Use (MU) Stage is your organization registering for?
Stage 1
Stage 2

What certified technology will generate the MU compliant message?
Vendor:

Version: