COVID-19 Data Collection Survey Tool Questions | Bureau of Primary Health Care

Effective: 4/5/24

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

The COVID-19 Data Collection Survey Tool User Guide can assist you in completing the survey.

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	How many of your patients received a test for SARS-CoV-2 virus detection (PCR, antigen) in the previous calendar month? (Testing refers to specimen collection regardless of where the specimen is processed. Do not include tests for antibody detection (serology).)	[Please enter a numerical value excluding commas (ex. 123123)]	Number Field
5	In the previous calendar month, has your health center administered COVID-19 vaccines received from any source?	[Select from the list]	Pick list: Yes No
5a This question is presented if the response to question 5 is “Yes”. Otherwise, this question is skipped.	By race and ethnicity, how many patients received a COVID-19 vaccine dose in the previous calendar month? [Enter the number of patients who received an FDA-approved vaccine in the previous calendar month.] 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	In the previous calendar month, 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?	[Select from the list]	Pick list: Yes No
6a This question is presented if the response to question 6 is “Yes.” Otherwise, it is skipped.	In the previous calendar month, how many mobile van, pop-up, school-based, and/or family vaccination clinics did you host for COVID-19 vaccinations?	[Please enter a numerical value excluding commas (ex. 123123)]	Number Field
6b This question is presented if the response to question 6 is “Yes.” Otherwise, it is skipped.	Of these clinics, how many were hosted in collaboration with a community- or faith-based organization?	[Please enter a numerical value commas (ex. 123123)]	Number Field
7	Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.		[Free text]

Date Last Reviewed:

April 2024