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COVID-19 Data Collection Survey Tool Questions

Effective: 11/3/23

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

The COVID-19 Data Collection Survey Tool User Guide can assist you in completing the survey.

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 How many of your patients received a test for SARS-CoV-2 virus detection (PCR, antigen) in the previous calendar month? (Testing refers to specimen collection regardless of where the specimen is processed. Do not include tests for antibody detection (serology).) [Please enter a numerical value excluding commas (ex. 123123)]

Number Field

5

In the previous calendar month, has your health center distributed test kits received through the HRSA COVID-19 Testing Supply Program?

[Select from the list] Pick list:

  • Yes
  • No

5a 

This question is presented if the response to question 5 is “Yes.” Otherwise, it is skipped.

In the previous calendar month, how many test kits received through the HRSA COVID-19 Testing Supply Program has your health center distributed? [Please enter a numerical value excluding commas (ex. 123123)] Number Field
6 In the previous calendar month, has your health center provided COVID-19 oral antiviral medication received through the HRSA Health Center COVID- 19 Therapeutics Program to patients? [Select from the list] Pick list:

  • Yes
  • No

6a

(This question is presented if the response to question 6 is “Yes.” Otherwise, it is skipped.)

By race and ethnicity, in the previous calendar month, how many patients have received a course of COVID-19 oral antiviral medication from the allocation you received through the HRSA Health Center COVID-19 Therapeutics Program?

[Enter the number of patients who received a course of an FDA-authorized COVID-19 oral antiviral medication in the previous calendar month, by race and ethnicity below.

NOTE: Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.]
 

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

6b

(This question is presented if the response to question 6 is “Yes.” Otherwise, it is skipped.)

 

By population type, in the previous calendar month, how many patients have received a course of COVID-19 oral antiviral medication from the allocation you received through the HRSA Health Center COVID-19 Therapeutics Program?

[Enter the number of patients who received a course of an FDA-authorized oral antiviral medication, by population type below.

NOTE: Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.]

  1. Migratory/Seasonal Agricultural Workers
  2. Individuals Experiencing Homelessness
  3. Residents of Public Housing
  4. Individuals with Limited English Proficiency
  5. Children (less than 18 years)
[Please enter a numerical value excluding commas (ex.123123)] Number Field
7 In the previous calendar month, has your health center administered COVID-19 vaccines received from any source? [Select from the list] Pick list:

  • Yes
  • No

7a

This question is presented if the response to question 7 is “Yes”. Otherwise, this question is skipped.

By race and ethnicity, how many patients received a COVID-19 vaccine dose in the previous calendar month?

[Enter the number of patients who received an FDA-approved vaccine in the previous calendar month.]

 

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 In the previous calendar month, did your health center utilize mobile vans or host pop-up, school-based, and/or family vaccination clinics to enhance access to COVID-19 vaccination sites? [Select from the list] Pick list:

  • Yes
  • No
8a

This question is presented if the response to question 8 is “Yes.” Otherwise, it is skipped.

In the previous calendar month, how many mobile van, pop-up, school-based, and/or family vaccination clinics did you host for COVID-19 vaccinations? [Please enter a numerical value excluding commas (ex. 123123)] Number Field

8b

This question is presented if the response to question 8 is “Yes.” Otherwise, it is skipped.

Of these clinics, how many were hosted in collaboration with a community- or faith-based organization?

[Please enter a numerical value commas (ex. 123123)] Number Field
9 Please provide any additional information, comments, or challenges you are experiencing due to COVID-19.   [Free text]
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