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COVID-19 Data Collection Survey Tool Questions

Effective: 10/7/22

As part of COVID-19 (Coronavirus) emergency-response efforts, we are asking health centers to fill out a biweekly survey to help track health center capacity and the impact of COVID-19 on health center operations, patients, and staff. The Health Resources and Services Administration will use the information collected to better understand training and technical assistance, funding, and other health center resource needs.

Important:

  • For questions that ask about initiating a COVID-19 immunization series, only include doses administered that are the first of a two-dose immunization series (for example, Pfizer or Moderna vaccines).
  • For questions that ask about completing a COVID-19 immunization series, include doses administered as a one-dose vaccine series (for example, Janssen COVID-19 (Johnson & Johnson) vaccine) as well as doses that are the second of a two-dose immunization series (for example, Pfizer or Moderna vaccines).

To ensure our nation's underserved communities and those disproportionately affected by COVID-19 are equitably vaccinated against COVID-19, HRSA and CDC launched the Health Center COVID-19 Vaccine Program to directly allocate a limited supply of COVID-19 vaccine to select HRSA-funded health centers.

For Health Center COVID-19 Vaccine Program participants ONLY: If you are a health center participating in this joint HRSA – CDC program, you are required to respond to ALL data reporting elements in this biweekly HRSA Health Center COVID-19 survey AND the addendum by the requested deadline.

To streamline reporting, health centers that ONLY administered vaccines from the Health Center COVID-19 Vaccine Program during the biweekly reporting period will skip questions 10, 11, and 12 in the first part of the survey and provide this information ONLY in the survey addendum.

Note: Health centers not enrolled in the Health Center COVID-19 Vaccine Program will not see question 9 or the addendum questions.

Question Number Question Field Description Answer Field
1 Please enter your email address: [you@example.com] [text field]
2 Please select the State/Territory that your health center is located in: [Select an answer choice from the list] Pick list of all the states + U.S. territories
3 Please select your health center name and associated Grant Number: [Select an answer choice from the list] Pick list of all of the health centers + active H80 grants
4 On average for this two-week period, how quickly is your health center able to obtain COVID-19 test results for SARS-CoV-2 virus detection (PCR, antigen)? (Do not include test processing times for antibody detection (serology).) [Select answer choices from the list]

Select one:

  • < 1 hour
  • 1-24 hrs
  • > 24 hrs
  • NA
5

By race and ethnicity, how many of your patients received a test for SARS-CoV-2 virus detection (PCR, antigen) in the last two weeks? (Testing refers to specimen collection regardless of where the specimen is processed. Do not include tests for antibody detection (serology).)

[Enter the number of patients tested by race and ethnicity below]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number field
6

By race and ethnicity, how many of your patients have tested positive for SARS-CoV-2 virus detection (PCR, antigen) in the last two weeks? (Report all positive results regardless of where patients were tested. Do not include positive test results for antibody detection (serology).)

[Enter the number of patients who tested positive for SARS-CoV-2 virus detection (PCR, antigen) by race and ethnicity below.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number field
7 In the last two weeks, has your health center distributed test kits received through the HRSA COVID-19 Testing Supply Program? [Select from the list] Pick List:

  • Yes
  • No
7a

This question is presented if the response to question 7 is “Yes.” Otherwise, it is skipped.

In the last two weeks, how many test kits received through the HRSA COVID-19 Testing Supply Program has your health center distributed? [Please enter a numerical value excluding commas (ex. 123123)] Number Field
8 In the last two weeks, has your health center distributed N95 masks received through the HRSA Health Center COVID-19 N95 Mask Program? [Select from the list] Pick List:

  • Yes
  • No
8a

This question is presented if the response to question 8 is “Yes.” Otherwise, it is skipped.

In the last two weeks, how many N95 masks received through the HRSA Health Center COVID-19 N95 Mask Program has your health center distributed? [Please enter a numerical value excluding commas (ex. 123123)] Number Field

9

NOTE: This question will ONLY be visible to Health Center COVID-19 Vaccine Program participants.

In the last two weeks, were all of the COVID-19 vaccine doses you administered received ONLY through the Health Center COVID-19 Vaccine Program?

(If you administered COVID-19 vaccine doses received from your state or any other vaccine source, you must select No.)

[Select from the list] Pick List

  • Yes
  • No

10

This question is presented if question 9 is skipped OR if the response to question 9 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks?

[Enter the number of patients who initiated an FDA-approved vaccine series in the last two weeks, by race and ethnicity below.]

[Enter the number of patients vaccinated by race and ethnicity below.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field

11

This question is presented if question 9 is skipped OR if the response to question 9 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks?

[Enter the number of patients who completed an FDA-approved vaccine series in the last two weeks, by race and ethnicity below.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field

12

This question is presented if question 9 is skipped OR if the response to question 9 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, by race and ethnicity below.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
13 Did your health center utilize mobile vans or host pop-up, school-based, and/or family vaccination clinics to enhance access to COVID-19 vaccination sites in the last two weeks? [Select from the list] Pick List:

  • Yes
  • No

13a

This question is presented only if the response to question 13 is “Yes.” Otherwise, it is skipped.

How many mobile van, pop-up, school-based, and/or family vaccination clinics did you host in the last two weeks for COVID-19 vaccinations? [Please enter a numerical value excluding commas (ex. 123123)] Number Field

14

How many doses of monoclonal antibody therapy have you administered in the last two weeks? [Please enter a numerical value excluding commas (ex. 123123)] Number field (must be 0 or greater)
15 In the last two weeks, has your health center provided COVID-19 oral antiviral medication received through the HRSA Health Center COVID-19 Therapeutics Program to patients? [Select from the list] [Pick list single select]:

  • Yes
  • No
15a

This question is presented if the response to question 15 is “Yes.” Otherwise, it is skipped.

By race and ethnicity, in the last two weeks, how many patients have received a course of COVID-19 oral antiviral medication from the allocation you received through the HRSA Health Center COVID-19 Therapeutics Program?

[Enter the number of patients who received a course of an FDA-authorized COVID-19 oral antiviral medication in the last two weeks, by race and ethnicity below.

NOTE: Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex.123123)] Number Field

15b

This question is presented if the response to question 15 is “Yes.” Otherwise, it is skipped.

By population type, in the last two weeks, how many patients have received a course of COVID-19 oral antiviral medication from the allocation you received through the HRSA Health Center COVID-19 Therapeutics Program?

[Enter the number of patients who received a course of an FDA-authorized oral antiviral medication, by population type below.

NOTE: Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.]

  1. Migratory/Seasonal Agricultural Workers
  2. Individuals Experiencing Homelessness
  3. Residents of Public Housing
  4. Individuals with Limited English Proficiency
  5. Children (less than 18 years)
[Please enter a numerical value excluding commas (ex.123123)] Number Field
16 Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.   [Free text]

Required Addendum for Participants of the Health Center COVID-19 Vaccine Program

As a condition of participation in this program, health centers are required to complete both the Health Center COVID-19 Biweekly Survey and additional questions outlined in the addendum below. Only health centers identified for participation in the Health Center COVID-19 Vaccine Program to receive a direction allocation of the COVID-19 vaccine are required to respond to these additional questions.

The information collected from these additional questions will assist HRSA and CDC to:

  • Assess COVID-19 vaccine administration capacity;
  • Monitor COVID-19 vaccine administration progress;
  • Evaluate the impact of the program to inform subsequent vaccine allocations; and
  • Identify training and technical assistance needs of participating health centers and their service delivery sites.

Please refer to the COVID-19 Data Collection Survey Tool User Guide to assist you in completing the additional questions outlined below.

Question Number Question Field Description Answer Field
17

By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who initiated an FDA-approved vaccine series in the last two weeks, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

[Enter the number of patients vaccinated by race and ethnicity below]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
18

By race and ethnicity, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who completed an FDA-approved vaccine series in the last two weeks, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
19

By race and ethnicity, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

Hispanic/Latino

  • 1a - Asian
  • 1b1 - Native Hawaiian
  • 1b2 - Other Pacific Islander
  • 1c - Black/African American
  • 1d - American Indian/Alaska Native
  • 1e - White
  • 1f - More than One Race
  • 1g - Unreported/Refused to Report Race

Subtotal Hispanic/Latino

Non-Hispanic/Latino

  • 2a - Asian
  • 2b1 - Native Hawaiian
  • 2b2 - Other Pacific Islander
  • 2c - Black/African American
  • 2d - American Indian/Alaska Native
  • 2e - White
  • 2f - More than One Race
  • 2g - Unreported/Refused to Report Race

Subtotal Non-Hispanic/Latino

Unreported/Refused to Report Race and Ethnicity

  • h - Unreported/Refused to Report Race and Ethnicity

i - Total

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
20

By population type, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who initiated an FDA-approved vaccine series in the last two weeks, by disproportionately affected populations below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

  1. Migratory/Seasonal Agricultural Workers
  2. Individuals Experiencing Homelessness
  3. Residents of Public Housing
  4. Individuals with Limited English Proficiency
  5. Children (less than 18 years)
[Please enter a numerical value excluding commas (ex. 123123)] Number Field
21

By population type, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who completed an FDA-approved vaccine series in the last two weeks, by disproportionately affected populations below. Only report on vaccines that are allocated from the Health Center COVID-19 Vaccine Program.]

  1. Migratory/Seasonal Agricultural Workers
  2. Individuals Experiencing Homelessness
  3. Residents of Public Housing
  4. Individuals with Limited English Proficiency
  5. Children (less than 18 years)
Please enter a numerical value excluding commas (ex. 123123)] Number Field
22

By population type, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, by disproportionately affected populations below. Only report on vaccines that are allocated from the Health Center COVID-19 Vaccine Program.]

  1. Migratory/Seasonal Agricultural Workers
  2. Individuals Experiencing Homelessness
  3. Residents of Public Housing
  4. Individuals with Limited English Proficiency
  5. Children (less than 18 years)
Please enter a numerical value excluding commas (ex. 123123)] Number Field
Date Last Reviewed: