DHS COVID Tracking - User Change Request
Use this form to request a new user to respond on behalf of your organization in the DHS COVID Tracking Tool. Once submitted, the new user will receive an email notification that their account is active in the tool. This process takes a few business days to complete.
Required fields are denoted with an asterisk (*).
User Information
Please answer question Tool Access before continuing.
Please answer question First Name before continuing.
Please answer question Last Name before continuing.
Please answer question Email before continuing.
Your answer to question Email must be a valid email address.
Your answer is shorter than the minimum allowed length of 3 characters.
Facility/Provider Information
Please enter the following identifying information of the facility/provider that the user will be reporting on behalf of. Either a License Number, Facility ID, or MPI is required.
Please answer question Program Office before continuing.
Please answer question Facility Type before continuing.
Please answer question Facility Name before continuing.
Please answer question FEIN before continuing.
Your answer is shorter than the minimum allowed length of 9 characters.
Your answer of %2 for question FEIN may only contain the following characters 0123456789.
Your answer of %2 for question Facility ID may only contain the following characters 0123456789.
Your answer of %2 for question MPI may only contain the following characters 0123456789.
Your answer of %2 for question Service Location Code may only contain the following characters 0123456789.