COVID-19 Data Collection Survey Tool User Guide

Effective: 04/09/21

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 week” or “this week.” This refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

 

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

12 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 17a |18 | 19

 

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.

2020a |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:

Does your health center currently have the ability to test patients for COVID-19? (Testing refers to specimen collection regardless of where the specimen is processed. Include tests for SARS-CoV-2 virus detection (PCR, antigen) only. Do not include tests for antibody detection (serology).)

Instructions: 

Select Yes or No. If the need arose, could your health center test a patient for COVID-19? Testing refers to specimen collection regardless of where the specimen is processed. Please only include your ability to test for SARS-CoV-2 virus (PCR, antigen) detection.

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

Question 5:

On average for this week, 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
  • 12 hours or less
  • 24 hours
  • 2-3 days
  • 4-5 days
  • More than 5 days

Instructions:

(This question does not appear if you answered No for Question 4.) 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

Question 6:

By race and ethnicity, how many of your patients received a test for SARS-CoV-2 virus detection (PCR, antigen) in the last week? (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:

(This question does not appear if you answered No for Question 4.) 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

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:

By race and ethnicity, how many of your patients have tested positive for SARS-CoV-2 virus detection (PCR, antigen) in the last week? (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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

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 8:

How many health center staff members have tested positive for COVID-19 in the last week? (Report positive results for viral detection (PCR, antigen) tests only. Do not include positive test results for antibody detection (serology).)

Instructions:

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

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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

The intent of this question is to find out how many of your staff had a final, positive COVID-19 test result within the last week.

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • Include positive staff test results whether or not the testing was done at your site or processed by your lab.
  • Do not include pending tests; only include positive test results.

Question 9:

How many of your health center sites were temporarily closed due to COVID-19 this week? (Include only those sites in your HC program scope of project.)

Instructions:

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

“This week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

The intent of this question is to find out how many sites within your approved scope of project were closed because of COVID-19 at any time within the past week.

  • Do not include closed sites that are not in your approved scope of project.
  • A “closed site” means that no services included in the scope of your health center program were offered at this site.
  • If services were offered from a site via telehealth, then the site is not considered closed because services within scope were still offered.
  • If only some services within scope were offered, the site is not considered to be closed.
  • Include sites that were closed for any portion of the last week within normal operating hours.
  • If a site was closed more than a week and is still closed, include it in this number.
  • If a site was closed for any portion of the last week and has since re-opened, include it in this number.
  • This number should include sites temporarily closed for any reason related to COVID-19 (i.e., supplies, staffing, etc.).
  • If a school-based site where behavioral health services are offered is closed due to school closure, include it in this number.

Question 10:

How does this last week’s 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

This is the percentage increase or decrease of visits for this week compared to pre-COVID. For example:

Prior to COVID-19, Health Center XYZ had an average of 200 visits each week. In this last week, Health Center XYZ had roughly 300 visits. 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 11:

What percentage of your health center’s visits in the last week 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

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 week.
  • Your response should reflect the percentage of all health center program visits offered remotely in the last week. For example, if your health center program had a total of 1,000 visits within the last week, 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 12:

Does your health center have an adequate supply of PPE (e.g., masks, gloves, gowns, etc.) to serve your patients?

Instructions:

Select Yes or No. You can use the text box to enter additional information you want us to know about this topic.

Question 13:

How many health center staff members have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week?

[Enter the number of staff who initiated an FDA-approved vaccine series in the last week below.] [Note: Exclude vaccines administered to health center staff 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.]

Instructions:

Enter the number of staff who initiated an FDA-approved vaccine series in the last week. 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. If a staff member received a COVID-19 vaccination during the last week and you have a record of the immunization, please include them in your count.

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

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • “Last week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

Question 14:

How many health center staff members have completed (2nd, or only, dose received) their COVID-19 immunization series in the last week?

[Enter the number of staff who completed an FDA-approved vaccine series in the last week below.] [Note: Exclude vaccines administered to health center staff 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.]

Instructions:

Enter the number of staff who completed an FDA-approved vaccine series in the last week. 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. If a staff member received a COVID-19 vaccination during the last week and you have a record of the immunization, please include them in your count.

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

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • “Last week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

Question 15:

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

[Enter the number of patients who initiated an FDA-approved vaccine series in the last week, 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.]

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 week 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 who are captured in a separate question.

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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

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

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

[Enter the number of patients who completed an FDA-approved vaccine series in the last week, 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 week, 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 who are captured in a separate question.

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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 5, then the reporting period is from Saturday, January 30, through Friday, February 5.

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 17

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

Instructions:

Select the answer(s) that apply for your health center:

  • Yes – Mobile vans
  • Yes – Pop-up clinics
  • 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. 

“Last week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, April 9, then the reporting period is from Saturday, April 3, through Friday, April 9.

Question 17a

How many mobile van clinics and/or pop-up clinics did you host in the last week for COVID-19 vaccinations?

[Required if response to Question 17 is ‘Yes’]

[Skip if response to Question 17 is ‘No’]

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 gymnasiums in different locations on the same day, you should count that as two (2) toward your total answer.
  • If you hosted pop-up clinics in two different locations on Monday, Wednesday, and Friday, you should count that as six (6) toward your total answer.

“Last week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, April 9, then the reporting period is from Saturday, April 3, through Friday, April 9.

Question 18

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 19

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 week.

Question 20

In the past week, 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 20a

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 20 is ‘No’]

[Skip if response to Question 20 is ‘Yes’]

Instructions:

If you answered No to Question 20, you must provide a response here to explain that answer.

If you answered Yes to Question 20, you may skip this question.

Question 21

How many health center staff members have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week 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 week 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 week. 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

Question 22

How many health center staff members have completed (2nd, or only, dose received) their COVID-19 immunization series in the last week 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 week 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 week. 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

Question 23

By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week 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 week, 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 week by race and ethnicity. 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 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

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 race and ethnicity, how many patients have completed (2nd, or only, dose received) their COVID-19 immunization series in the last week 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 week, 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 week 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

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 25

By population type, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week 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 week, 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

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 week 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

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.

  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.

Question 26

By population type, how many patients have completed (2nd, or only, dose received) their COVID-19 immunization series in the last week 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 week, 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

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 week 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 week” refers to 12:00 a.m. on the previous Saturday through 11:59 p.m. on this Friday. For example, if you are completing the survey that opened on Friday, February 26, then the reporting period is from Saturday, February 20, through Friday, February 26.

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.

  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.
Date Last Reviewed:  April 2021