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COVID-19 Data Collection Survey Tool User Guide

Effective: 11/3/23

This user guide will assist you in completing the COVID-19 data collection survey.

The survey helps HRSA track health center capacity and the impact of COVID-19 on health center operations, patients, and staff. The information will be used to better understand training and technical assistance, funding, and other health center resource needs. Please note that sub-awardees need to be included in reported results. The intent of the survey is to collect data on ALL activity funded by the Health Center Program. This includes non-patient individuals if Health Center Program funds were used to test or vaccinate them.

Beginning with the report of June 2023 data, this survey is now monthly. (Previously it was biweekly.) Many of the survey questions use the language “in the previous calendar month.” This refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30). 

To quickly access the instructions associated with a specific question, please select the question number.

1 | 2 | 3 | 4 | 5 | 5a | 6 | 6a6b | 7 | 7a | 8 | 8a8b9

Question 1:

Please enter your email address:

Instructions:

Enter a valid email address to which the confirmation of survey submission will be sent.

Question 2:

Please select the State/Territory that your health center is located in:

Instructions:

Choose the State/Territory listed in your Notice of Award in the Electronic Handbooks (EHBs).

Question 3:

Please select your health center name and associated Grant Number:

Instructions:

Choose the health center name and grant number listed in your Notice of Award in the EHBs.

Question 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).)

Instructions:

 Enter a numerical value excluding commas (ex. 123123). This is the 2021 UDS code:

Line Service Category Applicable ICD-10-CM, CPT-4/II, or HCPCS Code

 

Selected Diagnostic Tests/Screening/Preventive Services

 

21c

Novel coronavirus (SARS-CoV-2) diagnostic test

CPT-4: 87426, 87635, 87636, 87637

HCPCS: U0001, U0002, U0003, U0004

CPT PLA: 0202U, 0223U, 0225U, 0240U, 0241U

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Question 5:

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

Instructions:

Select your answer from the list: 

  • Yes
  • No

Select “Yes” only if your health center registered to participate in the HRSA COVID-19 Testing Supply Program, received test kits, and then distributed at least one of those test kits. 

If your health center is registered but has NOT yet received test kits, or if your health center has not registered for this program, please select “No.” 

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Question 5a:

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

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

Instructions:

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

Enter the number of test kits you distributed. Only include test kits received through the HRSA COVID-19 Testing Supply Program. Do NOT include test kits received through other sources. 

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).
 

Question 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?

Instructions: 

Select from the list: 

  • Yes 
  • No 

Answer “No” if your health center is not participating in this program. If you are participating, but did not provide any therapeutics received through the program to patients during this time period, answer “No.”  

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Question 6a

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.]

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

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

Instructions:

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

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity. Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF - 4 MB)

Question 6b

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.]

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

  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)

Instructions:

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

Please enter a numerical value excluding commas (ex. 123123) for each population. Only report courses allocated under the HRSA Health Center COVID-19 Therapeutics Program.

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Here are the UDS definitions for these populations. The first three definitions appear in Appendix H (Glossary) of the 2021 UDS Manual (PDF - 4 MB); the last definition appears in Table 3B, line 12. 

  1. Migratory/Seasonal Agricultural Workers refers to individuals whose principal employment is in agriculture, who have been so employed within 24 months, and who establish for the purposes of such employment a temporary abode. This includes dependent family members of the individuals and individuals who are no longer employed in migratory or seasonal agriculture because of age or disability who are within such a catchment area.

    For either migratory or seasonal agricultural workers, report patients who meet the definition of agriculture farming in all its branches, as defined by the Office of Management and Budget (OMB)-developed North American Industry Classification System (NAICS), and include seasonal workers included in codes 111 and 112 and all sub-codes therein, including sub-codes 1151 and 1152.

  2. Individuals Experiencing Homelessness refers to a person who lacks housing (without regard to whether the individual is a member of a family), including individuals whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations and individuals who reside in transitional housing. May include people at risk of homelessness, homeless veterans, and veterans at risk of homelessness.
  3. Residents of Public Housing refers to an individual residing in public housing agency-developed, -owned, or -assisted low-income housing, including mixed finance projects but excluding housing units with no public housing agency support other than Section 8 housing vouchers.
  4. Individuals with Limited English Proficiency refers to individuals who are best served in a language other than English, including those who are best served in sign language. This includes individuals who were served in a second language by a bilingual provider and those who may have brought their own interpreter and patients residing in areas where a language other than English is the dominant language, such as Puerto Rico or the Pacific Islands.
  5. Children (less than 18 years) refers to patients who were younger than 18 at the time of treatment.
     

Question 7:

In the previous calendar month, has your health center administered COVID-19 vaccines received from any source?

Instructions: 

Select from the list: 

  • Yes 
  • No 

Select “Yes,” if your health center administered even one COVID-19 vaccine dose to a patient. The source of the vaccine does not matter. It could have been ordered through your state, jurisdiction, or HRSA’s program. 

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Question 7a:

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.]

Note: Exclude vaccines administered to health center patients while participating in clinical trials.

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

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

Instructions:

Note: This question will NOT appear to anyone who answered “No” to question 7.

Enter  the number of patients who received a dose of an FDA-approved vaccine in the previous calendar month by race and ethnicity.

We’re asking about the number of people who received the vaccination anywhere, not just at your health center. Include both health center patients your health center vaccinated and health center patients who may have received the vaccination elsewhere (if you have a record of the immunization). Also include the count of all other individuals (i.e. non-health center patients) to whom you provided the COVID-19 vaccine, with the exception of your staff.

Note: Exclude vaccines administered to health center patients while participating in clinical trials.

Please enter a numerical value excluding commas (ex. 123123) for each race and ethnicity.

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Ethnicity determines whether a person identifies as Hispanic or Latino.

Race refers to a person’s self-identification with one or more social groups listed here as 1a-1g and 2a-2g.

All patients must be classified in one of the racial or ethnic categories.

  • Patients who self-report race but do not separately indicate if they are Hispanic or Latino are categorized as non-Hispanic/Latino.
  • Patients who self-report as Hispanic/Latino ethnicity but do not separately select a race are categorized as Hispanic/Latino ethnicity with “Unreported/Refused to Report” race. Do not default these patients to “White,” “American Indian/Alaska Native,” “more than one race,” or any other category.

For more detailed guidance on race/ethnic reporting, please refer to Table 3B: Demographic Characteristics in the 2021 UDS Manual (PDF - 4 MB) (PDF - 4.1 MB).

Question 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?

Instructions:

Select your answer from the list:

  • Yes
  • No

Mobile van clinics are defined as events requiring the use of a customized motor vehicle.

Pop-up clinics are defined as temporary locations or sites that have been repurposed for the intent of vaccinating patients. Examples include, but are not limited to, gymnasiums, parking lots, and recreation centers. These clinics are typically short-term, for example, an evening or a day.

School-based vaccination clinics include vaccination programs delivered on-site or in coordination with schools or organized child care centers to improve immunization rates in children and adolescents.

Family vaccination clinics are intended for the whole family—offering primary vaccinations and booster shots for everyone eligible. Family vaccination clinics include events hosted on-site and off-site (e.g., mobile van, pop-up, or school-based clinics). 

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).
 

Question 8a:

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? 

[This question is presented only if the answer to 8 is “Yes.” Otherwise, it is skipped.]

Instructions: 

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

Enter a numerical value. 

Each day should count as separate to your total. The count should reflect unique locations per day.

Here are some examples: 

  • If you hosted a mobile van clinic in the same location on Monday, Wednesday, and Friday, you should count that as three (3) toward your total answer. 
  • If you hosted two pop-up clinics in local recreation centers in different locations on the same day, you should count that as two (2) toward your total answer. 
  • If you hosted school-based clinics in two different locations on Monday, Wednesday, and Friday, you should count that as six (6) toward your total answer. 

For the number of family vaccination clinics, please count the number of events that meet the definition: Family vaccination clinics are intended for the whole family—offering primary vaccinations and booster shots for everyone eligible.  Family vaccination clinics include events hosted on-site and off-site (e.g., mobile van, pop-up, or school-based clinics). Please use the same guidance as above relating to unique locations per day. 

The phrase “in the previous calendar month” refers to the calendar month prior to the one in which the survey is taken. For example, in July, health centers will report data for the entire month of June (Thursday, June 1, through Friday, June 30).

Question 8b

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

[This question is presented only if the answer to 8 is “Yes.” Otherwise, it is skipped.]

Instructions: 

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

Enter a numerical value. Your response should be equal to or less than your response to 8a.  

Examples of community- and faith-based organizations include Women Infants and Children (WIC), Head Start, and other early childhood partners; organizations that serve older adults, people with disabilities, or other targeted sub-populations; groups that focus on housing, food security, employment, education, behavioral health services, or health-related social needs; and other organizations that bring people together, like places of worship and charities. 

Question 9:

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

Instructions:

The intent of this question is to allow you to offer any additional relevant information BPHC should know.

  • If you need to explain a previous answer, include the explanation here.
  • If you need to tell us about an issue we did not ask about, enter it here.
  • Do not include any Personally Identifiable Information (PII) or Personal Health Information (PHI) about yourself or others in your response. 
Date Last Reviewed: