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COVID-19 Data Collection Survey Tool Questions

Effective: 2/25/22

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 11, 12, and 13 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 10 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
7b

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

In the last two weeks, how has your health center distributed the test kits received through the HRSA COVID-19 Testing Supply Program? [Select all answers that apply from the list]

[Pick list multi-select]

  • Provided to existing health center patients who came to the health center (including for vaccination clinics)
  • Provided to the general public who came to the health center (including for vaccination clinics)
  • Provided at special vaccination events (e.g., through mobile vans, pop-up clinics, school-based clinics, family vaccination clinics)
  • Provided at other community events
  • Provided to migratory/seasonal agricultural workers directly or through partnerships with community organizations serving these individuals
  • Provided to individuals with limited English proficiency directly or through partnerships with community organizations serving these individuals
  • Provided to older adults and/or individuals with disabilities directly or through partnerships with community organizations serving these individuals
  • Provided to school-age children and/or their families directly or through partnerships with schools
  • Provided to individuals living in HUD-assisted housing and/or individuals experiencing homelessness directly or through partnerships with local housing authorities
  • Other—Please specify [free text/optional]
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
8b

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

In the last two weeks, how has your health center distributed the N95 masks received through the HRSA Health Center COVID-19 N95 Mask Program? [Select all answers that apply from the list] [Pick list multi-select]

  • Provided to existing health center patients who came to the health center (including for vaccination clinics)
  • Provided to the general public who came to the health center (including for vaccination clinics)
  • Provided at special vaccination events (e.g., through mobile vans, pop-up clinics, school-based clinics, family vaccination clinics)
  • Provided at other community events
  • Provided to migratory/seasonal agricultural workers directly or through partnerships with community organizations serving these individuals
  • Provided to individuals with limited English proficiency directly or through partnerships with community organizations serving these individuals
  • Provided to older adults and/or individuals with disabilities directly or through partnerships with community organizations serving these individuals
  • Provided to school-age children and/or their families directly or through partnerships with schools
  • Provided to individuals living in HUD-assisted housing and/or individuals experiencing homelessness directly or through partnerships with local housing authorities
  • Other—Please specify [free text/optional]
9

What percentage of your health center’s visits in the last two weeks were virtual (e.g., telehealth/telephonic)? (Consider all visits regardless of service type (e.g., medical, dental, behavioral health, etc.).)

[Select an answer choice] Slider – Range 0-100 Interval of 5

10

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

11

This question is presented if question 10 is skipped OR if the response to question 10 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

12

This question is presented if question 10 is skipped OR if the response to question 10 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

13

This question is presented if question 10 is skipped OR if the response to question 10 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
14 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

14a

This question is presented only if the response to question 14 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?

Mobile van clinics
Pop-up clinics
School-based vaccination clinics
Family vaccination clinics

[Please enter a numerical value for each type excluding commas (ex. 123123)] Four Number Fields
15

What challenges does your health center face in deploying the COVID-19 vaccine?

  • None
  • Vaccine supply
  • Vaccine storage capacity
  • Staffing to administer the vaccine
  • Financial reimbursement for costs associated with vaccine administration
  • Vaccine confidence
  • Other – please specify

[Select all answers that apply from the list]

[Please briefly describe the challenges]

Pick List Multi-select (subcategory choices)

[Free text is optional]

16 Does your health center provide access (e.g., direct provision or through referrals) to monoclonal antibody therapies? [Select from the list] Pick List:

  • Yes
  • No

16a

This question is presented only if the response to question 16 is “Yes.” Otherwise, it is skipped.

Which method(s) do you use to provide access to monoclonal antibody therapies?

[Select from the list]

[Both choices may be selected]

[In order to select more than one choice, press and hold the CTRL button while clicking on multiple options]

Pick List:

  • Direct provision of monoclonal antibody therapies
  • Refer patients to another organization that provides monoclonal antibody therapies

16b

This question is presented only if the response to question 16a is “Direct provision…” Otherwise, it is skipped.

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)

16c

This question is presented only if the response to question 16 is “No.” Otherwise, it is skipped.

What are your top barriers/challenges related to providing access to monoclonal antibody therapies?

  • Access to therapeutics
  • Patient awareness/education
  • Staffing capacity
  • Therapy administration/on-site logistics
  • Other (enter free text)

[Select all answers that apply from the list]

[Please briefly describe the challenges]

[In order to select more than one choice, press and hold the CTRL button while clicking on multiple options]

Pick List Multi-select (subcategory choices)

[Free text is optional]

17 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
17a

This question is presented if the response to question 17 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

17b

This question is presented if the response to question 17 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
18 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
19 How many health center staff members 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 staff who initiated an FDA-approved vaccine series in the last two weeks below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Please enter a numerical value excluding commas (ex. 123123)] Number Field
20

How many health center staff members 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 staff who completed an FDA-approved vaccine series in the last two weeks below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
21

How many health center staff members 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 staff who received an additional or booster dose of an FDA-approved vaccine in the last two weeks below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
22

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
23

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
24

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
25

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
26

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
27

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: