Form 2 Health Center COVID-19 Vaccine Program Readiness Assessm

OMB #: 0906-0062
Expires: XX/XX/202X

Health Center COVID-19 Vaccine Program Readiness Assessment
Purpose: This document outlines questions to assess the readiness and interest of HRSAsupported health centers identified by CDC and HRSA to receive a direct allocation of a limited
supply of COVID-19 vaccines as part of the Health Center COVID-19 Vaccine Program.
Note this document is a preview only. Complete and submit the Readiness Assessment within
the Health Center COVID-19 Vaccine Program Online Community. Submit one Readiness
Assessment per health center organization.
Part 1 of 2: Readiness Assessment
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 have 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) Please
explain why you do not want to participate at this time.
2. Are you currently receiving COVID-19 vaccines from the state (including from the
county)? (Y/N)
➔ If so, what is the weekly allocation? (Enter number of doses per week.)
3. Where do you currently report data on COVID-19 vaccine administration and outcomes?
(Select one or more from the following.)
o Electronic health records (enter vendor name)
o State’s Immunization Information System (enter IIS name)
o Vaccine Administration Management System (VAMS)
o Vaccine Adverse Event Reporting System (VAERS)
o HRSA Health Center COVID-19 Weekly Survey
o Other (comment field)
4. 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)
5. 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)
6. 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)
7. If this direct allocation program allows for vaccine redistribution across service delivery
sites, is an effective inventory management and distribution process in place to service
delivery sites? (Y/N)
8. 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)
Readiness Assessment Preview – Last Updated 4/27/2021

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OMB #: 0906-0062
Expires: XX/XX/202X

Part 2 of 2: My Sites
9. We would like to know more about your current COVID-19 vaccine capacity and details
for the site(s) you would like to participate in this direct allocation program that will
complement state and jurisdiction programs. Select one or more sites.
➔ Select the sites you propose for this direct allocation. Organization Name is your
site name. HRSA recently pulled the list of sites from your health center's Form
5B, and filtered the list to remove administrative-only and mobile sites.
➔ For sites selected, complete the following:
o Site Name Correction: If the name of your site is incorrect from the list of
sites, provide the name correction.
o Has this site already received COVID-19 vaccines from the
state/jurisdiction? (Y/N)
o If known, provide the state/jurisdiction VTrckS PIN for this site. The VTrckS
PIN is commonly 4-10 alphanumeric characters.
Note: As part of the provider agreement process, the state/jurisdiction
assigns the site a unique VTrckS PIN to order vaccines from the
state/jurisdiction allocation. In addition, to participate in the HRSA Vaccine
Program, selected health center sites will be assigned a new federal
VTrckS PIN to receive federal allocation of vaccines. If you would like
assistance confirming a site’s VTrcks PIN, please contact your local or state
Immunization Program Manager. Your state Primary Care Association
(PCA) may also be able to assist in finding this information.
o Confirm address of the site is accurate (including any suite or room
number).
o Confirm address of the site is accurate for receiving vaccine deliveries
(Y/N)
o If address is inaccurate for receiving deliveries, provide correction in open
comment field, Vaccine Shipping Address Correction.
o Provide special instructions for delivery in the open comment field.
o Site VPoP point of contact name, email and phone number: This person will
receive the “Welcome” email from VPoP to access the portal and place
vaccine orders. Once VPoP accounts are created, each health center may
update and add POCs based upon operational needs and preference.
o Site hours vaccine deliveries may occur, by day of week, including any
hours closed for lunch or other breaks. Check the box if the site is close or
cannot accept deliveries on a certain day.

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 0906-0062 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].

Readiness Assessment Preview – Last Updated 4/27/2021

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