COVID-19 Data Collection Survey Tool Questions

Revised 5/12/20

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

Question Number Question Field Description Answer Field
1 Please select the State/Territory that your health center is located in: [Select an answer choice from the list] Pick list of all the states + U.S. territories
2 Please select your health center name and associated Grant Number: [Select an answer choice from the list] Pick list of all of the health centers + active H80 grants
3 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)? [Select an answer choice from the list] Pick list Y/N
4 Does your health center currently have walk-up/drive-up COVID-19 testing sites? [This question does not appear if N was selected for Question 3.] [Select an answer choice from the list] Pick list Y/N
5 On average for this week, how quickly is your health center able to obtain COVID-19 test results? [This question appears only if Yes was answered for either of the above questions.]
[Select answer choices from the list]
Select one:
• 12 hours or less
• 24 hrs
• 2-3 days
• 4-5 days
• More than 5 days
6

By race and ethnicity, how many patients has your health center tested for COVID-19 in the last week?
(Testing refers to specimen collection regardless of where the specimen is processed)

[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

[Please enter a numerical value excluding commas (ex. 123123)] Number field
7

By race and ethnicity, how many patients at your health center have tested positive for COVID-19 in the last week? (Report all positive patients regardless of where they were tested)

[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

[Please enter a numerical value excluding commas (ex. 123123)] Number field
8 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] [With 100% being average, <100% being below average, >100% being above average] Slider - range 10- 150 interval of 5
9 How many of your health center sites were temporarily closed due to COVID-19 in the last week? (Include only those sites in your HC program scope) [Please enter a numerical value excluding commas (ex. 123123)] Number field
10 How many staff members at your health center have tested positive for COVID-19 in the last week? [Please enter a numerical value excluding commas (ex. 123123)] Number field
11 What percentage of 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? [Select an answer choice] Slider – range 0-100 interval of 5
12 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.)] [Select an answer choice] Slider – range 0-100 interval of 5
13 Will your health center have an adequate supply of PPE (e.g., masks, gloves, gowns, etc.) to serve your patients next week? [Select an answer choice from the list]

Pick list Y/N

If response is N, then list of checkboxes for what is needed:

  • surgical masks
  • N95/PPR masks
  • gowns
  • gloves
  • face masks/goggles
14 Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.   Free text
Date Last Reviewed:  May 2020