• Each individual that will be responsible for completing the ‘KY Lab Information and Registry’ daily should complete this access request form. Remember to complete all required fields (identified by an asterisk (*)) and select the ‘Submit’ button at the bottom of the form.
• Owner entity means the legal business name for the entity that owns your lab. This can be the lab itself or a parent company.
• Affiliate DBA (doing business as) is the name the reporting lab uses for day to day transactions and communications
• Affiliate entity is the differentiating legal name of the reporting Lab. If the lab is self-owned then use the Owner legal name.
• Email: If you already have a Kentucky Online Gateway (KOG) account, you should use the same email address. If you do not have a KOG account already, you may need to create one. If you are unsure, we will let you know. It is recommended that you use your lab assigned email address.
• Phone Number: This phone number provided may be used if we need to contact you regarding your access and/or account or if there are questions related to the lab reported data you have provided. Phone number format should be (000) 000-0000 followed by x0000 if an extension is necessary.
• Please Note: Once you ‘Submit’, you will not be able to edit, please validate that the information provided is accurate. You only need to submit one form.

Please Note: The Contact is the person the State may engage in case of a question for the lab.

Please Note: The Requestor is the person who will be entering the daily reports on behalf of the lab.

If you are requesting to report for more than one lab under an Owner Entity, please list the lab information in the box above, do not submit more than one form.