Form 1 Coronavirus 2019 (COVID-19) Data Report Form

OMB Number (0906-0053)

Expires: XX/XX/202X

Proposed COVID-19 Data Report (CDR)

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the numbers of RWHAP clients and immediate household members served for treatment or prevention of COVID-19 and the types of allowable RWHAP services provided with CARES Act RWHAP funding. HAB will use these data to show how CARES Act RWHAP funding is being used to support RWHAP clients (and immediate household members in limited circumstances) and to identify potential changes in RWHAP needs and service provision during and beyond the COVID-19 pandemic. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0906-0053 and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (FY 2020 Coronavirus Aid, Relief, and Economic Security Act- P.L. 116-136). Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].

SECTION 1: Organization-level activities
What services were provided using telehealth during the reporting period? NOTE: Report all service categories that used telehealth during the reporting period whether or not CARES Act funds were used for the service.	☐ Do not have telehealth capacity for any service/ Do not provide telehealth for any services Select all that apply1 Core Medical Services: ☐ AIDS Drug Assistance Program (ADAP) Treatments ☐ AIDS Pharmaceutical Assistance ☐ Early Intervention Services (EIS) ☐ Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals ☐ Home and Community-Based Health Services ☐ Home Health Care ☐ Hospice ☐ Medical Case Management, including Treatment Adherence Services ☐ Medical Nutrition Therapy ☐ Mental Health Services ☐ Oral Health Care ☐ Outpatient/Ambulatory Health Services ☐ Substance Abuse Outpatient Care Support Services: ☐ Child Care Services ☐ Emergency Financial Assistance ☐ Food Bank/Home Delivered Meals ☐ Health Education/Risk Reduction ☐ Housing ☐ Linguistic Services ☐ Medical Transportation ☐ Non-Medical Case Management Services ☐ Other Professional Services ☐ Outreach Services ☐ Psychosocial Support Services ☐ Referral for Health Care and Support Services ☐ Rehabilitation Services ☐ Respite Care ☐ Substance Abuse Services (residential)
SECTION 2: Clients served
Is your provider site conducting COVID-19 testing? If yes, how many RWHAP-eligible clients and immediate household members were tested for COVID-19 in the reporting period?	[Yes/No] #
Total number of RWHAP-eligible clients served in the reporting period with NEWLY IDENTIFIED COVID-19 (confirmed or presumed positive).2	#
Total number RWHAP-eligible clients with COVID-19 (confirmed or presumed) served to-date as of [end date of the reporting period]3	#
Instructions: Answer the following questions for the services provided using CARES Act funds for the prevention or treatment of COVID-19: The table below should only include the number of RWHAP-eligible clients and immediate household members who received at least 1 service in the reporting period. Those who received RWHAP services under multiple service categories should be counted one time in each service category.
	Number of RWHAP-eligible clients and immediate household members who received service(s) in the reporting period4
Total number of RWHAP-eligible clients and immediate household members receiving CARES Act funded services in the reporting period.	#
Core Medical Services
AIDS Drug Assistance Program (ADAP) Treatments	#
AIDS Pharmaceutical Assistance	#
Early Intervention Services (EIS)	#
Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals	#
Home and Community-Based Health Services	#
Home Health Care	#
Hospice	#
Medical Case Management, including Treatment Adherence Services	#
Medical Nutrition Therapy	#
Mental Health Services	#
Oral Health Care	#
Outpatient/Ambulatory Health Services	#
Substance Abuse Outpatient Care	#
Support Services
Child Care Services	#
Emergency Financial Assistance	#
Food Bank/Home Delivered Meals	#
Health Education/Risk Reduction	#
Housing	#
Linguistic Services	#
Medical Transportation	#
Non-Medical Case Management Services	#
Other Professional Services	#
Outreach Services	#
Psychosocial Support Services	#
Referral for Health Care and Support Services	#
Rehabilitation Services	#
Substance Abuse Services (residential)	#

¹ Refer to PCN 16-02 for information on service category definitions and the Examples of CARES Act Funding by Service Category.

² Number of RWHAP-eligible clients who received a new positive test result for COVID-19 or were presumed positive during the reporting period, regardless of where testing took place. Do not include immediate household members.

³ Cumulative number of RWHAP-eligible clients with COVID-19 (or presumed positive) since January 20, 2020, served by the provider as of the last day of the reporting period. Do not include immediate household members.

⁴ In each funded service category, include RWHAP-eligible clients and immediate household members who received the service using CARES Act RWHAP funds during the reporting period, for COVID-19 related prevention or treatment activities. Refer to the Examples of CARES Act Funding by Service Category for details on allowable services for immediate household members.