Form 1 FORM 1 - Health Center COVID-19 Vaccine Program – Readin

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Health Center COVID-19 Vaccine Program – Readiness Assessment Week 2

Notes for Salesforce Community Integration

Last updated 2/13/21

Survey Questions

1. If you were to receive a direct allocation of the COVID-19 vaccine starting the week after next (amount TBD), can you ensure that you can safely store the vaccine, and that you have trained and credentialed staff and sufficient Personal Protective Equipment (PPE) to administer the vaccine in a timely manner? (Y/N)

   • If Yes to Question 1, proceed with the following questions.

   • If No: Would you be interested in the near future (e.g., 1 to 2 weeks) of receiving a direct allocation of COVID-19 vaccine through this program? (Y/N) If Yes, proceed with the following questions.

2. Are you currently receiving COVID-19 vaccines from the state? (Y/N)

• If so, what is the weekly allocation? (Enter number of doses per week.)

3. We would like to know more about your current COVID-19 vaccine capacity and details on the sites you would like to participate in this direct allocation program that will complement state and jurisdiction programs.

   • Health centers participating in this direct allocation program will be assigned new VTrcks PINs to order from the federal allocation. Select sites for which you would like to propose this direct allocation.

     1. Note: This list of sites was recently pulled from your health center's Form 5B and is filtered to include only sites eligible for allocation: It does not include Administrative-only sites, mobile sites, or special site types (e.g., hospitals, school based)

   • For sites selected, complete the following:

   • How many COVID-19 vaccines doses can you administer weekly on top of your state allocation? (Number of doses per week.)

   • Site level point of contact: first name, last name, email address, phone number

   • Site level hours of operation by day of week, including any hours closed for lunch or other breaks (i.e., hours during which deliveries can occur)

4. Where do you currently report data on COVID-19 vaccine administration and outcomes? (Select one or more from the following.)

• Electronic health records (enter vendor name)

• State’s Immunization Information System (enter IIS name)

• Vaccine Administration Management System (VAMS)

• Vaccine Adverse Event Reporting System (VAERS)

• HRSA Health Center COVID-19 Weekly Survey

• Other (comment field)

5. Do you have standing meetings with your state or local department of health contact to discuss vaccine administration and related lessons learned and challenges? (Y/N)

6. Do you have a vaccine coordinator (and back-up coordinator) supporting your center and service delivery sites? (Note: A vaccine coordinator is the point of contact for receiving vaccine shipments, monitoring storage unit temperatures, managing vaccine inventory, etc. See Section 5 of CDC COVID-19 Vaccination Program Interim Playbook for more information.) (Y/N)

7. Does your health center have a process/system in place to schedule and manage COVID-19 vaccination appointments and reminders? (Y/N)

   • If Yes: How will you get patients back for their second dose? Do you have a reminder/recall system available? (Open comment field to explain/describe)

8. If this direct allocation program allows for redistribution of vaccines across service delivery sites, do you have an effective process for inventory management and distribution of vaccines to service delivery sites in place? (Y/N)

9. To administer the COVID-19 vaccine to hard-to-reach, difficult-to-find patients disproportionately impacted by COVID-19, do you have a plan for vaccine transport (e.g., for mobile vaccination sites to reach farmworkers, rural residents, etc.)? (Y/N)

Public Burden Statement:  Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center COVID-19 Vaccine Program is part of a White House Initiative with the goal of administering 100 million shots in 100 days, with a focus on equity. In a collaboration between HRSA and the Centers for Disease Control and Prevention (CDC), this program will directly allocate a limited supply of COVID-19 vaccines to select HRSA-funded health centers.  These forms provide HRSA with the information essential for Health Center COVID-19 Vaccine Program evaluation and determination of whether an individual health centers should participate in the program.  The OMB control number for this information collection is 0906-xxxx and it is valid through XX/XX/202X. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average .5 hour 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]. 

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OMB # 0906-xxxx

Expires: xx/xx/20xx