COVID-19 Data Collection Survey Tool User Guide

Effective: 10/23/20

This user guide is intended to 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 them.

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:

Does your health center currently have walk-up/drive-up COVID-19 testing sites?

Instructions: 

(This question does not appear if No was answered for question 3.) Select yes or no. Select yes if you have either walk-up or drive-up testing, or if you have both. You do not need to have both to answer yes.

Question 6:

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 No was answered for question 3.) 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

Question 7:

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 N was selected for Question 3.] 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

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 the UDS manual in Table 3B: Demographic Characteristics, which can be found on the UDS Resources website.

Question 8:

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

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.

Include all retests. Some patients may be duplicates.

  • 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 the UDS manual in Table 3B: Demographic Characteristics, which can be found on the UDS Resources website.

Question 9:

By race and ethnicity, how many of your patients received a test for antibody detection (serology) in the last week? (Testing refers to specimen collection regardless of where the specimen is processed. Do not include positive test results for virus detection (PCR, antigen).) [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  
21d Novel coronavirus (SARS-CoV-2) antibody test CPT-4: 86328, 86769

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.

Include all retests. Some patients may be duplicates.

  • 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 the UDS manual in Table 3B: Demographic Characteristics, which can be found on the UDS Resources website.

Question 10:

By race and ethnicity, how many of your patients have tested positive for antibody detection (serology) in the last week? (Report all positive results regardless of where patients were tested. Do not include positive test results for virus detection (PCR, antigen).) [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  
21d Novel coronavirus (SARS-CoV-2) antibody test CPT-4: 86328, 86769

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.

Include all retests. Some patients may be duplicates.

  • 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 the UDS manual in Table 3B: Demographic Characteristics, which can be found on the UDS Resources website.

Question 11:

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). Last week refers to the previous Saturday, 12:00 a.m. through this past Friday, 11:59 p.m. For example, if you are completing the survey on May 1, 2020, then the reporting period is from Saturday April 25, 2020 through Friday, May 1.

This is the 2020 UDS code:

Line Service Category Applicable ICD-10-CM, CPT-4/II, or HCOCS Code
  Selected Diagnostic Tests/ Screening/Preventive Services  
21c Novel coronavirus (SARS-CoV-2) diagnostic test CPT-4: 87635
HCPCS: U0001, U0002, U0003, U0004

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

  • Do not include volunteers. Count paid, full-time and part-time staff only.
  • 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.
  • Include all paid staff who work within the scope of your health center program.

Question 12:

What percentage of health center staff members were unable to work due to COVID-19 (e.g., due to site/service closure, exposure, family/home obligations, lack of PPE, etc.) in the last week?

Instructions:

Last week refers to the previous Saturday, 12:00 a.m. through this past Friday 11:59 p.m. For example, if you are completing the survey on May 1, 2020, then the reporting period is from Saturday April 25, 2020 through Friday, May 1.

Calculate (number of staff not working/total number of staff) x 100.

The intent of this question is to find out the percentage of your staff who were unable to work for any part of the last week due to any reason related to COVID-19.

  • Include all paid, full-time and part-time staff who work within your approved health center scope of project.
  • Do not include volunteers.
  • Include any reason related to COVID-19. Reasons could include site or service closure, exposure to COVID-19, lack of child care or other family obligations, illness of a family member, inability to pay the staff member (furloughed staff), inability to pass mandatory health screening, lack of supplies and/or PPE, exposure safety concerns, etc. If the reason a staff member is unable to work exists directly or indirectly from the COVID-19 pandemic, include them in this percentage.
  • If a staff member is able to actively work, do not include them in this number, even if they are working from home.
  • Your response should reflect the percentage of staff NOT able to work. For example, if 100 staff would normally work in the last week, and 30 of them could NOT work for a reason related to COVID-19, then your response should be 30%.
  • If you had no staff unable to actively work, your response should be 0%.

Question 13:

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). Last week refers to the previous Saturday, 12:00 a.m. through this past Friday, 11:59 p.m. For example, if you are completing the survey on May 1, 2020, then the reporting period is from Saturday, April 25, 2020 through Friday, May 1.

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 14:

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 the previous Saturday, 12:00 a.m. through this past Friday 11:59 p.m. For example, if you are completing the survey on May 1, 2020, then the reporting period is from Saturday April 25, 2020 through Friday, May 1.

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 leading up to the survey, the Health Center XYZ has had roughly 300 visits. Health Center XYZ should report 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 15:

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:

Last week refers to the previous Saturday, 12:00 a.m. through this past Friday, 11:59 p.m. For example, if you are completing the survey on May 1, 2020, then the reporting period is from Saturday, April 25, 2020 through Friday, May 1.

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

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.

  • 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 the UDS manual Appendix E: Other Data Elements, which can be found on the UDS Resources website.

Question 16:

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

(If your health center is not currently having supply challenges, please select "No supply challenge at this time," regardless of the number of days for which you have a supply in stock. Please also select this option if your health center does not use a particular item.)

  • Surgical masks
  • N95/PPR masks
  • Gowns
  • Gloves
  • Face masks/Goggles

Instructions:

The intent of this question is to find out whether you have enough PPE to provide services to your health center program patients.

  • Only consider supplies on hand. Do not consider shipments believed to be on the way.
  • To support your determination of adequate supply, consider proper use of all PPE supplies according to CDC guidelines for proper use.

Please select the appropriate indicator for how long each PPE item you have on hand is expected to last. Select "No supply challenges at this time" if your health center is not currently having supply challenges with an item, regardless of the number of days for which you have a supply in stock, or if your health center does not use a particular item.

  • 6 or fewer days
  • 7-13 days
  • 14-20 days
  • 21-27 days
  • 28 or more days
  • No supply challenge at this time

Question 17:

Is your health center experiencing challenges obtaining an adequate supply of flu vaccine doses?

Instructions:

Select yes or no. The intent of this question is to find out whether your health center is having any difficulty in obtaining the flu vaccine does you need.

Please select No if you are not experiencing any challenges.

If you are experiencing challenges, please select Yes, then briefly and clearly explain the challenge using the text box that will appear.

Question 18:

By race and ethnicity, how many flu vaccinations did your health center administer since August 1, 2020?

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.

The 2020 UDS seasonal flu vaccine codes are: CPT-4: 90630, 90653 through 90657, 90658, 90661, 90662, 90672, 90673, 90674, 90682, 90685 through 90689, 90756.

These are also listed on page 68 of the 2020 UDS Manual (PDF - 1.8 MB)

"Since August 2020" refers to the timeframe beginning August 1, 2020, through the current date.

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 the UDS manual in Table 3B: Demographic Characteristics, which can be found on the UDS Resources website.

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.
Date Last Reviewed:  October 2020