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COVID-19 Data Collection Survey Tool User Guide

Effective: 11/1/22

This user guide will assist you in completing the COVID-19 data collection survey.

The survey helps HRSA track health center capacity and the impact of COVID-19 on health center operations, patients, and staff. The information will be used to better understand training and technical assistance, funding, and other health center resource needs. Please note that sub-awardees need to be included in reported results. The intent of the survey is to collect data on ALL activity funded by the Health Center Program. This includes non-patient individuals if Health Center Program funds were used to test or vaccinate them.

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).

Many of the survey questions use the language “in the last two weeks” or “this two-week period.” This refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

To quickly access the instructions associated with a specific question, please select the question number.

1 | 2 | 3 | 4 | 5 | 6 | 7 | 7a8 | 8a9 | 10 | 11 | 12 | 13 | 13a | 14 | 15 | 15a | 15b | 16  

Addendum for Health Center COVID-19 Vaccine Program Participants Only
Health centers not enrolled in the Health Center COVID-19 Vaccine Program will not see the addendum questions.

17 | 18 | 19 | 20 | 21 | 22 

Question 1:

Please enter your email address:

Instructions:

Enter a valid email address to which the confirmation of survey submission will be sent.

Question 2:

Please select the State/Territory that your health center is located in:

Instructions:

Choose the State/Territory listed in your Notice of Award in the Electronic Handbooks (EHBs).

Question 3:

Please select your health center name and associated Grant Number:

Instructions:

Choose the health center name and grant number listed in your Notice of Award in the EHBs.

Question 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 one:

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

Instructions:

Select only one of the choices provided.

This is the 2021 UDS code:

Line Service Category Applicable ICD-10-CM, CPT-4/II, or HCPCS Code

 

Selected Diagnostic Tests/Screening/Preventive Services

 

21c

Novel coronavirus (SARS-CoV-2) diagnostic test

CPT-4: 87426, 87635, 87636, 87637

HCPCS: U0001, U0002, U0003, U0004

CPT PLA: 0202U, 0223U, 0225U, 0240U, 0241U

“This two-week period” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 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

Instructions:

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

This is the 2021 UDS code:

Line Service Category Applicable ICD-10-CM, CPT-4/II, or HCPCS Code

 

Selected Diagnostic Tests/Screening/Preventive Services

 

21c

Novel coronavirus (SARS-CoV-2) diagnostic test

CPT-4: 87426, 87635, 87636, 87637

HCPCS: U0001, U0002, U0003, U0004

CPT PLA: 0202U, 0223U, 0225U, 0240U, 0241U

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF - 4 MB).

Question 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 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

Instructions:

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

This is the 2021 UDS code:

Line Service Category Applicable ICD-10-CM, CPT-4/II, or HCPCS Code

 

Selected Diagnostic Tests/Screening/Preventive Services

 

21c

Novel coronavirus (SARS-CoV-2) diagnostic test

CPT-4: 87426, 87635, 87636, 87637

HCPCS: U0001, U0002, U0003, U0004

CPT PLA: 0202U, 0223U, 0225U, 0240U, 0241U

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Report all positive results regardless of where patients were tested. Do not include positive test results for antibody detection (serology). Include all retests. Some patients may be duplicates.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF - 4 MB).

Question 7:

In the last two weeks, has your health center distributed test kits received through the HRSA COVID-19 Testing Supply Program?

Instructions:

Select your answer from the list:

  • Yes
  • No

Select “Yes” only if your health center registered to participate in the HRSA COVID-19 Testing Supply Program, received test kits, and then distributed at least one of those test kits.

If your health center is registered but has NOT yet received test kits, or if your health center has not registered for this program, please select “No.”

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 7a:

In the last two weeks, how many test kits received through the HRSA COVID-19 Testing Supply Program has your health center distributed?

Instructions:

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

Enter the number of test kits you distributed. Only include test kits received through the HRSA COVID-19 Testing Supply Program. Do NOT include test kits received through other sources.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 8:

In the last two weeks, has your health center distributed N95 masks received through the HRSA Health Center COVID-19 N95 Mask Program?

Instructions:

Select your answer from the list:

  • Yes
  • No

Select “Yes” only if your health center registered to participate in the HRSA Health Center COVID-19 N95 Mask Program, received masks, and then distributed at least one of those masks. 

Though orders may no longer be placed, participants must continue to report the use of inventory received through the program until it is exhausted. 

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 8a:

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?

Instructions:

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

Enter the number of masks you distributed. Only include masks received through the HRSA Health Center COVID-19 N95 Mask Program. Do NOT include masks received through other sources.

Though orders may no longer be placed, participants must continue to report the use of inventory received through the program until it is exhausted. 

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 9:

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.)

Instructions:

NOTE: This question will ONLY be visible to Health Center COVID-19 Vaccine Program participants. If your health center does not participate in that program, the system will automatically skip this question and move you to question 10.

For Vaccine Program participants who see this question, select your answer from the list:

  • Yes
  • No

As the question indicates, if you administered any COVID-19 vaccine doses received by your state or any other vaccine source, you must select “No.”

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 10:

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

Instructions:

Note: This question will NOT appear to Health Center COVID-19 Vaccine Program participants who answered “Yes” to question 9.

Enter the number of patients who initiated an FDA-approved vaccine series in the last two weeks by race and ethnicity. ONLY include doses administered that are the first of a two-dose immunization series (for example, Pfizer or Moderna vaccines).

We’re asking about the number of people who received the vaccination anywhere, not just at your health center. Please include both health center patients your health center vaccinated and health center patients who may have received the vaccination elsewhere (if you have a record of the immunization). Also include the count of all other individuals (i.e. non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Note: Exclude vaccines administered to health center patients while participating in clinical trials.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 11

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

Instructions:

Note: This question will NOT appear to Health Center COVID-19 Vaccine Program participants who answered “Yes” to question 9.

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

We’re asking about the number of people who received the vaccination anywhere, not just at your health center. Please include both health center patients your health center vaccinated and health center patients who may have received the vaccination elsewhere (if you have a record of the immunization). Also include the count of all other individuals (i.e. non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Note: Exclude vaccines administered to health center patients while participating in clinical trials.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 12

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

Instructions:

Note: This question will NOT appear to Health Center COVID-19 Vaccine Program participants who answered “Yes” to question 9.

CDC has advised that severely immunocompromised patients receive an additional (third) dose of the Pfizer-BioNTech or Moderna COVID-19 mRNA vaccines as part of their primary vaccination. They have also released guidance on administration of booster shots. For more information on this guidance, visit CDC’s Vaccines for Specific Groups of People website (for information on additional doses) or CDC’s Booster Shots website.

Enter the number of patients who received an additional or booster dose during the past two weeks, by race and ethnicity.

We’re asking about the number of people who received an additional or booster dose anywhere, not just at your health center. Please include both health center patients your health center vaccinated and health center patients who may have received the vaccination elsewhere (if you have a record of the immunization). Also include the count of all other individuals (i.e. non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Note: Exclude vaccines administered to health center patients while participating in clinical trials.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 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?

Instructions:

Select from the list:

  • Yes
  • No

Mobile van clinics are defined as events requiring the use of a customized motor vehicle.

Pop-up clinics are defined as temporary locations or sites that have been repurposed for the intent of vaccinating patients. Examples include, but are not limited to, gymnasiums, parking lots, and recreation centers. These clinics are typically short-term, for example, an evening or a day.

School-based vaccination clinics include vaccination programs delivered on-site or in coordination with schools or organized child care centers to improve immunization rates in children and adolescents. 

Family vaccination clinics are intended for the whole family—offering primary vaccinations and booster shots for everyone eligible. Family vaccination clinics include events hosted on-site and off-site (e.g., mobile van, pop-up, or school-based clinics).

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 13a

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?

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

Instructions:

Enter a numerical value.

Each day should count as separate to your total. The count should reflect unique locations per day. Here are some examples:

  • If you hosted a mobile van clinic in the same location on Monday, Wednesday, and Friday, you should count that as three (3) toward your total answer.
  • If you hosted two pop-up clinics in local recreation centers in different locations on the same day, you should count that as two (2) toward your total answer.
  • If you hosted school-based clinics in two different locations on Monday, Wednesday, and Friday, you should count that as six (6) toward your total answer.

For the number of family vaccination clinics, please count the number of events that meet the definition: Family vaccination clinics are intended for the whole family—offering primary vaccinations and booster shots for everyone eligible. Family vaccination clinics include events hosted on-site and off-site (e.g., mobile van, pop-up, or school-based clinics). Please use the same guidance as above relating to unique locations per day.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 14

How many doses of monoclonal antibody therapy have you administered in the last two weeks?

Instructions:

Please enter a number.

Therapy refers to both IV treatment and subcutaneous treatment:

  • IV treatment:1 treatment = 1 dose
  • Subcutaneous treatment: 4 shots = 1 dose

If your health center has administered no doses during the time period, enter “0.”

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 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?

Instructions:

Select from the list:

  • Yes
  • No

Answer “No” if your health center is not participating in this program. If you are participating, but did not provide any therapeutics received through the program to patients during this time period, answer “No.” 

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Question 15a

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

Instructions:

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

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity. Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 15b

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)

Instructions:

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

Please enter a numerical value excluding commas (ex. 123123) for each population. Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2021 UDS Manual (PDF); the last definition appears in Table 3B, line 12.

  1. Migratory/Seasonal Agricultural Workers refers to individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.

    For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152.

  2. Individuals Experiencing Homelessness refers to a person who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include people at risk of homelessness, homeless veterans, and veterans at risk of homelessness.
  3. Residents of Public Housing refers to an individual residing in public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
  4. Individuals with Limited English Proficiency refers to individuals who are best served in a language other than English, including those who are best served in sign language. This includes individuals who were served in a second language by a bilingual provider and those who may have brought their own interpreter and patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
  5. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.

Question 16

Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.

Instructions:

The intent of this question is to allow you to offer any additional relevant information BPHC should know.

  • If you need to explain a previous answer, include the explanation here.
  • If you need to tell us about an issue we did not ask about, enter it here.
  • Do not include any Personally Identifiable Information (PII) or Personal Health Information (PHI) about yourself or others in your response.

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

This addendum will be visible ONLY to health centers that received vaccine through the Health Center COVID-19 Vaccine Program in the past two weeks.

Question 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.]

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

Instructions:

Only report on vaccines allocated from 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. ONLY include doses administered that are the first of a two-dose immunization series (for example, Pfizer or Moderna vaccines).
  • Include the count of all other individuals (i.e., non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 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

Instructions:

Only report on vaccines allocated from 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. 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).
  • Include the count of all other individuals (i.e. non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF)

Question 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

Instructions:

CDC has advised that severely immunocompromised patients receive an additional (third) dose of the Pfizer-BioNTech or Moderna COVID-19 mRNA vaccines as part of their primary vaccination. They have also released guidance on administration of booster shots. For more information on this guidance, visit CDC’s Vaccines for Specific Groups of People website (for information on additional doses) or CDC’s Booster Shots website.

Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program:

  • Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine series in the last two weeks by race and ethnicity.
  • Include the count of all other individuals (i.e. non-health center patients) to whom you provided an additional or booster dose of the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF).

Question 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)

Instructions:

Only report on vaccines allocated from 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 population (definitions below). ONLY include doses administered that are the first of a two-dose immunization series (for example, Pfizer or Moderna vaccines).
  • Include the count of all other individuals (i.e. non-health center patients) in these populations to whom you provided the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each population.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2021 UDS Manual (PDF); the last definition appears in Table 3B, line 12.

  1. Migratory/Seasonal Agricultural Workers refers to individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.

    For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152. 

  2. Individuals Experiencing Homelessness refers to a person who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include people at risk of homelessness, homeless veterans, and veterans at risk of homelessness. 
  3. Residents of Public Housing refers to an individual residing in public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
  4. Individuals with Limited English Proficiency refers to individuals who are best served in a language other than English, including those who are best served in sign language. This includes individuals who were served in a second language by a bilingual provider and those who may have brought their own interpreter and patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
  5. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.

Question 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)

Instructions:

Only report on vaccines allocated from 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 population (definitions below). 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).
  • Include the count of all other individuals (i.e. non-health center patients) in these populations to whom you provided the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each population.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2021 UDS Manual (PDF); the last definition appears in Table 3B, line 12.

  1. Migratory/Seasonal Agricultural Workers refers to individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.

    For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152.

  2. Individuals Experiencing Homelessness refers to a person who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include people at risk of homelessness, homeless veterans, and veterans at risk of homelessness.
  3. Residents of Public Housing refers to an individual residing in public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
  4. Individuals with Limited English Proficiency refers to individuals who are best served in a language other than English, including those who are best served in sign language. This includes individuals who were served in a second language by a bilingual provider and those who may have brought their own interpreter and patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
  5. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.

Question 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)

Instructions:

CDC has advised that severely immunocompromised patients receive an additional (third) dose of the Pfizer-BioNTech or Moderna COVID-19 mRNA vaccines as part of their primary vaccination. They have also released guidance on administration of booster shots. For more information on this guidance, visit CDC’s Vaccines for Specific Groups of People website (for information on additional doses) or CDC’s Booster Shots website.

Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program:

  • Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine series in the last two weeks by population (definitions below).
  • Include the count of all other individuals (i.e. non-health center patients) in these populations to whom you provided an additional or booster dose of the COVID-19 vaccine, with the exception of your staff.

Please enter a numerical value excluding commas (ex. 123123) for each population.

“Last two weeks” refers to 12:00 a.m. two Saturdays prior to the date the survey is sent through 11:59 p.m. on the Friday the survey opens. For example, if you are completing the survey that opened on Friday, January 14, then the reporting period is from Saturday, January 1, through Friday, January 14.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2021 UDS Manual (PDF); the last definition appears in Table 3B, line 12.

  1. Migratory/Seasonal Agricultural Workers refers to individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.

    For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152.

  2. Individuals Experiencing Homelessness refers to a person who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include people at risk of homelessness, homeless veterans, and veterans at risk of homelessness.
  3. Residents of Public Housing refers to an individual residing in public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
  4. Individuals with Limited English Proficiency refers to individuals who are best served in a language other than English, including those who are best served in sign language. This includes individuals who were served in a second language by a bilingual provider and those who may have brought their own interpreter and patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
  5. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.
Date Last Reviewed: