COVID-19 Data Collection Survey Tool Questions

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

Effective: 10/08/2021

As part of COVID-19 (Coronavirus) emergency-response efforts, we are asking health centers to fill out a biweekly 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 biweekly HRSA Health Center COVID-19 survey AND the addendum by the requested deadline.

To streamline reporting, health centers that ONLY administered vaccines from the Health Center COVID-19 Vaccine Program during the biweekly reporting period will skip questions 9, 10, and 11 in the first part of the survey and provide this information ONLY in the survey addendum.

Note: Health centers not enrolled in the Health Center COVID-19 Vaccine Program will not see question 8 or 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 On average for this two-week period, 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 answer choices from the list]

Select one:

  • < 1 hour
  • 1-24 hrs
  • > 24 hrs
  • NA
5

By race and ethnicity, how many of your patients received a test for SARS-CoV-2 virus detection (PCR, antigen) in the last two weeks? (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

[Please enter a numerical value excluding commas (ex. 123123)] Number field
6

By race and ethnicity, how many of your patients have tested positive for SARS-CoV-2 virus detection (PCR, antigen) in the last two weeks? (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
7

What percentage of your health center’s visits in the last two weeks 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

8

NOTE: This question will ONLY be visible to Health Center COVID-19 Vaccine Program participants.

In the last two weeks, were all of the COVID-19 vaccine doses you administered received ONLY through the Health Center COVID-19 Vaccine Program?

(If you administered COVID-19 vaccine doses received from your state or any other vaccine source, you must select No.)

[Select from the list] Pick List
  • Yes
  • No

9

This question is presented if question 8 is skipped OR if the response to question 8 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks?

[Enter the number of patients who initiated an FDA-approved vaccine series in the last two weeks, 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 vaccinated 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

This question is presented if question 8 is skipped OR if the response to question 8 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks?

[Enter the number of patients who completed an FDA-approved vaccine series in the last two weeks, 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

11

This question is presented if question 8 is skipped OR if the response to question 8 is “No.” Otherwise, it is skipped.

By race and ethnicity, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, 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.]

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
12 Did your health center utilize mobile vans, host pop-up clinics, and/or host school-based vaccination clinics to enhance access to COVID-19 vaccination sites in the last two weeks? [Select from the list] Pick List:
  • Yes 
  • No

12a

This question is presented only if the response to question 12 is “Yes.” Otherwise, it is skipped.

How many mobile van clinics, pop-up clinics, and/or school-based vaccination clinics did you host in the last two weeks for COVID-19 vaccinations?

Mobile van clinics
Pop-up clinics
School-based vaccination clinics

[Please enter a numerical value for each type excluding commas (ex. 123123)] Three Number Fields
13

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]

14 Does your health center provide access (e.g., direct provision or through referrals) to monoclonal antibody therapies? [Select from the list] Pick List:
  • Yes
  • No

15a

This question is presented only if the response to question 14 is “Yes.” Otherwise, it is skipped.

Which method(s) do you use to provide access to monoclonal antibody therapies?

[Select from the list]

[Both choices may be selected]

[In order to select more than one choice, press and hold the CTRL button while clicking on multiple options]

Pick List:
  • Direct provision of monoclonal antibody therapies
  • Refer patients to another organization that provides monoclonal antibody therapies

15b

This question is presented only if the response to question 15a is “Direct provision…” Otherwise, it is skipped.

How many doses of monoclonal antibody therapy have you administered in the last two weeks? [Please enter a numerical value excluding commas (ex. 123123)] Number field (must be 0 or greater)

15c

This question is presented only if the response to question 14 is “No.” Otherwise, it is skipped.

What are your top barriers/challenges related to providing access to monoclonal antibody therapies?
  • Access to therapeutics
  • Patient awareness/education
  • Staffing capacity
  • Therapy administration/on-site logistics
  • Other (enter free text)

 

[Select all answers that apply from the list]

[Please briefly describe the challenges]

[In order to select more than one choice, press and hold the CTRL button while clicking on multiple options]

Pick List Multi-select (subcategory choices)

[Free text is optional]

16 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 Biweekly 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
17 How many health center staff members have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks 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 two weeks 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
18

How many health center staff members have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks 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 two weeks 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
19

How many health center staff members received an additional or booster dose of COVID-19 vaccine in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program

[Enter the number of staff who received an additional or booster dose of an FDA-approved vaccine in the last two weeks below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.]

 

[Please enter a numerical value excluding commas (ex. 123123)] Number Field
20

By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks 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 two weeks, 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 vaccinated 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
21

By race and ethnicity, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks 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 two weeks, 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
22

By race and ethnicity, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine 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
23

By population type, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last two weeks 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 two weeks, 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
  5. Children (less than 18 years)
[Please enter a numerical value excluding commas (ex. 123123)] Number Field
24

By population type, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last two weeks 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 two weeks, 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
  5. Children (less than 18 years)
Please enter a numerical value excluding commas (ex. 123123)] Number Field
25

By population type, how many patients have received an additional or booster dose of COVID-19 vaccine in the last two weeks from vaccines allocated under the Health Center COVID-19 Vaccine Program?

[Enter the number of patients who received an additional or booster dose of an FDA-approved vaccine in the last two weeks, by disproportionately affected populations below. Only report on vaccines that are allocated from the Health Center COVID-19 Vaccine 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

 

Date Last Reviewed:  October 2021