COVID-19 Data Collection Survey Tool User Guide

Effective: 09/10/21

This user guide will assist you in completing the COVID-19 information 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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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

1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 11a | 12 | 13 | 14a | 14b | 14c | 15 | 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 | 17a | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26

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 2020 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: 87635
HCPCS: U0001, U0002, U0003, U0004

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 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: 87635
HCPCS: U0001, U0002, U0003, U0004

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 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 2020 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: 87635
HCPCS: U0001, U0002, U0003, U0004

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 MB).

Question 7:

How does this last two weeks’ number of visits compare to your average number of weekly visits pre-COVID-19? (Consider all visits regardless of service type (e.g., medical, dental, behavioral health, etc.), including virtual visits.)

Instructions:

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

This is the percentage increase or decrease of visits for the past two weeks compared to pre-COVID. For example:

Prior to COVID-19, Health Center XYZ had an average of 200 visits each week. In this past two weeks, Health Center XYZ had roughly 600 visits—an average of 300 visits per week during the two week-reporting period. Health Center XYZ should report that their average number of weekly visits compared to pre-COVID-19 is 150% (300 divided by 200 multiplied by 100%). Health Center XYZ’s denominator (average number of weekly visits pre-COVID-19) should remain the same from week to week.

Question 8:

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.).)

Instructions:

The intent of this question is to find out the percentage of visits within your approved health center scope of project were conducted remotely, via telephone, videoconference, etc.

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Calculate (number of virtual visits/total number of all visits) x 100.

  • Include all services offered under your approved health center scope of project in the last two weeks.
  • Your response should reflect the percentage of all health center program visits offered remotely in the last two weeks. For example, if your health center program had a total of 1,000 visits within the last two weeks, and 250 of them were conducted remotely, your response should be 25%.

For more detailed guidance on telehealth, please refer to Appendix E: Other Data Elements in the 2020 UDS Manual (PDF - 2 MB).

Question 9:

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.] [Note: Exclude vaccines administered to health center patients while participating in clinical trials.] [Note: If applicable, please include vaccine doses received under the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.] [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:

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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 MB).

Question 10

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.] [Note: Exclude vaccines administered to health center patients while participating in clinical trials.] [Note: If applicable, please include vaccine doses received under the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.]

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:

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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 MB).

Question 11

Did your health center utilize mobile vans, host pop-up clinics, and/or host school-based vaccination clinics to enhance access to COVID-19 vaccination sites in the last two weeks?

Instructions:

Select from the list:

  • Yes
  • No

Pop-up clinics can be 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.

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

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Question 11a

How many mobile van clinics, pop-up clinics, and/or school-based vaccination clinics did you host in the last two weeks for COVID-19 vaccinations?

Mobile van clinics

Pop-up clinics

School-based vaccination clinics

[This question is presented only if the answer to 11 is “Yes.” Otherwise, it is skipped.]

Instructions:

Enter a numerical value for each type.

Each day should count as separate to your total for a type. 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.

“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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Question 12

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

Instructions:

Select all items in the selection list that are challenges for your health center being able to deploy the COVID-19 vaccine.

In the optional text box, please provide additional detail that will help BPHC determine how to help address your health center’s challenges.

Question 13

Does your health center provide access (e.g., direct provision or through referrals) to monoclonal antibody therapies?

Instructions:

Select from the list:

  • Yes
  • No

Answer “Yes” even if your health center does not provide the therapies on-site, but does refer patients to another organization for the treatment.

Answer “No” if your health center does not provide the therapies on-site and does not refer patients to another organization for the treatment.

Question 14a

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

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

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

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

Instructions:

You may select either or BOTH options:

  • If your health center provides monoclonal antibody therapies on-site, select this option.
  • If your health center refers patients out for monoclonal antibody therapies, select this option.

Question 14b

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

[This question is presented only if the answer to 14a is “Direct provision...” Otherwise, it is skipped.]

Instructions:

Please enter a number.

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, August 27, then the reporting period is from Saturday, August 14, through Friday, August 27.

Question 14c

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

[This question is presented only if the answer to 13 is “No.” Otherwise, it is skipped.]

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

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

Instructions:

Select all the options that apply.

  • “Access to therapeutics” means not having a location offering monoclonal antibody therapeutics nearby. This includes situations in which your health center is unable to administer the monoclonal antibodies/convalescent plasma on-site.
  • “Patient awareness/education” means when a patient is unaware or has not received education from a health care professional about when and how monoclonal antibody therapy may be used to treat COVID-19. 
  • “Staffing capacity” means having an insufficient number of qualified staff available to provide monoclonal antibody treatment. 
  • “Therapy administration/on-site logistics” means being unable to manage the day-to-day functions involved in providing the monoclonal antibody treatment (for example, not having sufficient space or equipment). This does not include staffing issues; select “Staffing capacity” for those.

If you select “Other,” please provide an explanation.

Question 15

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

[Enter the number of patients who received an additional dose of an FDA-approved vaccine in the last two weeks, by race and ethnicity below.] [Note: Exclude vaccines administered to health center patients while participating in clinical trials.] [Note: If applicable, please include vaccine doses received under 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 recently advised that moderately to severely immunocompromised people receive an additional (third) dose of mRNA vaccines. Please see our August 16 bulletin HRSA BPHC exit disclaimer for information and resources.

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

We’re asking about the number of people who received an additional 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, September 10, then the reporting period is from Saturday, August 28, through Friday, September 10.

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 2020 UDS Manual (PDF - 2 MB).

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

In the past two weeks, has your health center been able to administer all COVID-19 vaccines allocated from the Health Center COVID-19 Vaccine Program?

Instructions:

Select Yes or No. 

Question 17a

Please briefly explain why your health center has not been able to administer all the vaccines received from the Health Center COVID-19 Vaccine Program. [Required if response to Question 17 is ‘No’]

[This question is presented only if the answer to 17 is “No.” Otherwise, it is skipped.]

Instructions:

If you answered No to Question 17, you must provide a response here to explain that answer.

Question 18

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.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.]

Instructions:

Enter the number of staff who initiated an FDA-approved vaccine series in the last two weeks. ONLY include doses administered that are the first of a two-dose immunization series (for example, Pfizer or Moderna vaccines). Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • “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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16. 

Question 19

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.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.]

Instructions:

Enter the number of staff who completed an FDA-approved vaccine series in the last two weeks. 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). Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • “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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Question 20

How many health center staff members received an additional 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 dose of an FDA-approved vaccine in the last two weeks below.]

Instructions:

CDC recently advised that moderately to severely immunocompromised people receive an additional (third) dose of mRNA vaccines. Please see our August 16 bulletin HRSA BPHC exit disclaimer for information and resources.

Enter the number of staff who received an additional dose of an FDA-approved vaccine series in the last two weeks. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • “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, September 10, then the reporting period is from Saturday, August 28, through Friday, September 10.

Question 21

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.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.]

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 who are captured in a separate question.

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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 MB).

Question 22

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.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.]

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 who are captured in a separate question.

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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

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 2020 UDS Manual (PDF - 2 MB).

Question 23

By race and ethnicity, how many patients have received an additional 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 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.]

Instructions:

CDC recently advised that moderately to severely immunocompromised people receive an additional (third) dose of mRNA vaccines. Please see our August 16 bulletin HRSA BPHC exit disclaimer for information and resources.

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

  • Enter the number of patients who received an additional 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 dose of the COVID-19 vaccine, with the exception of your staff who are captured in a separate question.

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, September 10, then the reporting period is from Saturday, August 28, through Friday, September 10.

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 2020 UDS Manual (PDF - 2 MB).

Question 24

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.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.]

  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 who are captured in a separate question.

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, July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2020 UDS Manual (PDF - 2 MB); 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. 

  1. 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. 
  1. 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. 
  1. 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.
  1. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.

Question 25

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.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.]

  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 who are captured in a separate question.

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 July 16, then the reporting period is from Saturday, July 3, through Friday, July 16.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2020 UDS Manual (PDF - 2 MB); 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.

  1. 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.
  2. 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.
  3. 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.
  4. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.

Question 26

By population type, how many patients have received an additional 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 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 recently advised that moderately to severely immunocompromised people receive an additional (third) dose of mRNA vaccines. Please see our August 16 bulletin HRSA BPHC exit disclaimer for information and resources.

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

  • Enter the number of patients who received an additional 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 dose of the COVID-19 vaccine, with the exception of your staff who are captured in a separate question.

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, September 10, then the reporting period is from Saturday, August 28, through Friday, September 10.

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2020 UDS Manual (PDF - 2 MB); 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.

  1. 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.
  2. 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.
  3. 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.
  4. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.
Date Last Reviewed:  September 2021