Effective: 4/5/24
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 | 6a | 6b | 7
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 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 5a:
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 5 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 5.
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 6:
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 6a:
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 6 is “Yes.” Otherwise, it is skipped.]
Instructions:
This question is presented only if the answer to 6 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 6b
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 6 is “Yes.” Otherwise, it is skipped.]
Instructions:
This question is presented if the response to question 6 is “Yes.” Otherwise, it is skipped.
Enter a numerical value. Your response should be equal to or less than your response to 6a.
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 7:
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.