COVID-19 Data Collection Survey Tool Questions

View this guide to assist in completing the COVID-19 information collection survey.

Effective: 10/23/20

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 enter your email address: [you@example.com] [text field]
2 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
3 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
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).) [Select an answer choice from the list] Pick list Y/N
5 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
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).) [This question does not appear if N was selected for Question 3.]
[Select answer choices from the list]

Select one:

  • < 1 hour
  • 12 hours or less
  • 24 hrs
  • 2-3 days
  • 4-5 days
  • More than 5 days
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

[This question does not appear if N was selected for Question 3. Please enter a numerical value excluding commas (ex. 123123)] Number field
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 for SARS-CoV-2 virus detection (PCR, antigen) 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
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

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

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

Number field
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).)

[Please enter a numerical value excluding commas (ex. 123123)] Number field
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? [Select an answer choice] Slider - Range 0-100 interval of 5
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.)

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

[With 100% being average, <100% being below average, >100% being above average]

Slider - Range 10-150 Interval of 5

 

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.).)

[Select an answer choice] Slider – Range 0-100 Interval of 5
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
[Select an answer choice for each type of PPE]

Pick an Option

  • 6 or fewer days
  • 7-13 days
  • 14-20 days
  • 21-27 days
  • 28 or more days
  • No supply challenge at this time
17 Is your health center experiencing challenges obtaining an adequate supply of flu vaccine doses? [Select an answer choice]

If Yes … [Please explain your challenges with flu vaccine doses in the comment box.]

Pick list Y/N

Yes: text field

18

By race and ethnicity, how many flu vaccinations did your health center administer since August 1, 2020?
[Enter the cumulative number of flu vaccinations administered since August 1, 2020, 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
19 Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.   [Free text]

 

Date Last Reviewed:  October 2020