Form 4 ADDENDUM Health Center COVID-19 Vaccine Program

OMB # 0906-0062

Expires: XX/XX/202X

Required Addendum for Participants of the Health Center COVID-19 Vaccine Program

As a condition of participation in this program, health centers are required to complete both the Health Center COVID-19 Weekly Survey and additional questions outlined in the addendum below. Only health centers identified for participation in the Health Center COVID-19 Vaccine Program to receive a direction allocation of the COVID-19 vaccine are required to respond to these additional questions.

The information collected from these additional questions will assist HRSA and CDC to:

• Assess COVID-19 vaccine administration capacity;

• Monitor COVID-19 vaccine administration progress;

• Evaluate the impact of the program to inform subsequent vaccine allocations; and

• Identify training and technical assistance needs of participating health centers and their service delivery sites. 

Please refer to the COVID-19 Data Collection Survey Tool User Guide to assist you in completing the additional questions outlined below.

Health Center Name and Grant Number (Please include)

Question Number	Question Field	Description	Answer Field
20	In the past week, has your health center been able to administer all COVID-19 vaccines allocated from the Health Center COVID-19 Vaccine Program?	[Select an answer choice from the list]
20a [Required if response to Question 20 is ‘No’] [Skip if response to Question 20 is ‘Yes’]	Please briefly explain why your health center has not been able to administer all the vaccines received from the Health Center COVID-19 Vaccine Program.
21	How many health center staff members have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of staff who initiated an FDA-approved vaccine series in the last week below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.]	[Please enter a numerical value excluding commas ( ex. 123123)]
22	How many health center staff members have completed (2nd , or only, dose received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of staff who completed an FDA-approved vaccine series in the last week below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.]	[Please enter a numerical value excluding commas ( ex. 123123)]
23	By race and ethnicity, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of patients who initiated an FDA-approved vaccine series in the last week, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.] [Enter the number of patients tested by race and ethnicity below] 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	[Please enter a numerical value excluding commas ( ex. 123123)]
24	By race and ethnicity, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of patients who completed an FDA-approved vaccine series in the last week, by race and ethnicity below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.] 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	[Please enter a numerical value excluding commas ( ex. 123123)]
25	By population type, how many patients have initiated (1st of 2 doses received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of patients who initiated an FDA-approved vaccine series in the last week, by disproportionately affected populations below. Only report on vaccines allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, ONLY report those in the COMPLETED dose question.] Migratory/Seasonal Agricultural Workers Individuals Experiencing Homelessness Residents of Public Housing Individuals with Limited English Proficiency Children (less than 18 years)	[Please enter a numerical value excluding commas ( ex. 123123)]
26	By population type, how many patients have completed (2nd , or only, dose received) their COVID-19 immunization series in the last week from vaccines allocated under the Health Center COVID-19 Vaccine Program? [Enter the number of patients who completed an FDA-approved vaccine series in the last week, by disproportionately affected populations below. Only report on vaccines that are allocated from the Health Center COVID-19 Vaccine Program.] [Note: If you are administering a one-dose vaccine series, report those in this question as completed.] Migratory/Seasonal Agricultural Workers Individuals Experiencing Homelessness Residents of Public Housing Individuals with Limited English Proficiency Children (less than 18 years)	Please enter a numerical value excluding commas ( ex. 123123)]

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 future vaccination allocations.  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 1 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].