COVID-19 Data Collection Survey Tool Questions

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

Effective: 04/09/21

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.

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).

To ensure our nation's underserved communities and those disproportionately affected by COVID-19 are equitably vaccinated against COVID-19, HRSA and CDC launched the Health Center COVID-19 Vaccine Program to directly allocate a limited supply of COVID-19 vaccine to select HRSA-funded health centers.

For Health Center COVID-19 Vaccine Program participants ONLY: If you are a health center participating in this joint HRSA – CDC program, you are required to respond to ALL data reporting elements in this weekly HRSA Health Center COVID-19 survey AND the addendum by the requested deadline.

Note: Health centers not enrolled in the Health Center COVID-19 Vaccine Program will not see the addendum questions.

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 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 4.]
[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
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

[This question does not appear if N was selected for Question 4. Please enter a numerical value excluding commas (ex. 123123)] Number field
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 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
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).)

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

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

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

Slider - Range 10-150 Interval of 5

 

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.).)

[Select an answer choice] Slider – Range 0-100 Interval of 5
12 Does your health center have an adequate supply of PPE (e.g., masks, gloves, gowns, etc.) to serve your patients? [Select an answer choice from the list]

Pick list Y/N [Free text optional]

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.]

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

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

[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
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

[Please enter a numerical value excluding commas ( ex. 123123)] Number Field
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? [Select all that apply from the list] Pick List
  • Yes – Mobile vans
  • Yes – Pop-up clinics
  • No

 17a

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

How many mobile van clinics and/or pop-up clinics did you host in the last week for COVID-19 vaccinations? [Please enter a numerical value excluding commas (ex. 123123)] Number Field
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

[Select all answers that apply from the list]

[Please briefly describe the challenges]

Pick List Multi-select (subcategory choices)

[Free text is optional]

19 Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.   [Free text]

Required Addendum for Participants of the Health Center COVID-19 Vaccine Program

As a condition of participation in this program, health centers are required to complete both the Health Center COVID-19 Weekly Survey and additional questions outlined in the addendum below. Only health centers identified for participation in the Health Center COVID-19 Vaccine Program to receive a direction allocation of the COVID-19 vaccine are required to respond to these additional questions.

The information collected from these additional questions will assist HRSA and CDC to:

  • Assess COVID-19 vaccine administration capacity;
  • Monitor COVID-19 vaccine administration progress;
  • Evaluate the impact of the program to inform subsequent vaccine allocations; and
  • Identify training and technical assistance needs of participating health centers and their service delivery sites. 

Please refer to the COVID-19 Data Collection Survey Tool User Guide to assist you in completing the additional questions outlined below.

Question Number Question Field Description Answer Field
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? [Select an answer choice from the list] Pick List Y/N

20a

[Required if response to Question 20 is ‘No’]

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

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.   [Free text]
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.] [Please enter a numerical value excluding commas ( ex. 123123)] Number Field
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.]

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

[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
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

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

 

Date Last Reviewed:  April 2021