Form 1 HRSA FORHP COVID-19 Data Report_9.18.2020

OMB Number (0906-XXXX)

Expires: XX/XX/202X

Proposed Rural Health Clinic COVID-19 Testing Program Data Report (RHC CTR) – Pending OMB approval

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of Rural Health Clinic (RHC) organizations, number of COVID-19 tests conducted, and the types of allowable RHC services provided with RHC COVID-19 Testing funding. FORHP will use these data to show how RHC COVID-19 Testing funding is used. 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-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (FY 2020 Paycheck Protection Program and Health Care Enhancement Act- P.L. 116-139). Public reporting burden for this collection of information is estimated to average .25 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 paperwork@hrsa.gov.

URLs
RHCCovidReporting.com
RHCCovidReporting.org
Title of Webpage
Rural Health Clinic COVID-19 Testing Report
Step 1 - Splash Page (Eligibility + Privacy Statement)
Introduction
The Department of Health and Human Services (HHS) has announced $225 million for rural health clinics (RHCs) to provide COVID-19 testing as a mandated by the Paycheck Protection Program and Health Care Enhancement Act. This program resulted in an amount of $49,461.42 for each eligible RHC. This site allows rural health clinics to report information related to their testing activities as required in the terms and conditions of the RHC COVID-19 Testing Program.
Public Burden Statement
The purpose of this data collection system is to collect aggregate data on the number of Rural Health Clinic (RHC) organizations, number of COVID-19 tests conducted, and the types of allowable RHC services provided with RHC COVID-19 Testing funding. FORHP will use these data to show how RHC COVID-19 Testing funding is used. 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-XXXX and it is valid until XX/XX/202X. This information collection is required to obtain or retain a benefit (FY 2020 Paycheck Protection Program and Health Care Enhancement Act- P.L. 116-139). Public reporting burden for this collection of information is estimated to average .25 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 paperwork@hrsa.gov.
Privacy Act Statement
The following statement serves to inform you of the purpose for collecting personal information required by the RHCCovidReporting.com and how it will be used.
AUTHORITY: Paycheck Protection Program and Health Care Enhancement Act (Public Law No: 116-139). This page is managed by the National Association of Rural Health Clinics under cooperative agreement G27RH39211 with the Federal Office of Rural Health Policy, Health Resources and Services Administration (HRSA).
PURPOSE: To collect information per the requirements as specified in the terms and conditions for the “Rural Testing Relief Fund,” also known as the RHC COVID-19 Testing Program. This reporting system does not replace any other reporting requirements that RHC organizations may have with respect to COVID-19, such as those required for public health surveillance purposes.
ROUTINE USES: The information collected will be used by HRSA to monitor and assess the effectiveness of the funding provided to Rural Health Clinics (RHCs) for COVID-19 testing and related expenses.
DISCLOSURE: Voluntary. From October 1 through October 15, 2020, HRSA is providing RHCs with early access to the reporting system for funded organizations that wish to begin entering data in alignment with the proposed measures under the pending reporting requirement. At a point in the future, HRSA will require reporting and inform RHCs of the requirement pending final approval from the Office of Management and Budget.
Eligibility
Did you or your organization, as represented by a tax identification number (TIN), receive funds for Rural Health Clinic COVID-19 testing through the Paycheck Protection Program and Health Care Enhancement Act?
YES [directs to sign in/registration]
NO [directs to final page]
YES, but my TIN organization returned all such funds [directs to final page]
NO, but I believe my TIN organization is eligible for this program [directs user to submit contact information]
IF User selects “No but I believe my TIN organization is eligible for this program” user is directed to provide:
[Name Email Name of Organization TIN of Organization CMS Certification Numbers (also known as CCN or PTAN numbers) of RHC's Owned by your Organization]
CONTINUE Button
Step 2 – Registration
[Standard 2 factor authentication sign-in/registration]1
Step 3 – Profile Creation
Introduction
As a part of the Rural Health Clinic (RHC) COVID-19 Testing Program, the Department of Health and Human Services (HHS), allocated $225 million among all eligible rural health clinics $49,461.42 for each eligible clinic. Organizations that own multiple RHCs should have received $49,461.42 times the number of eligible RHCs they own.
This money was allocated to organizations through their tax identification number (TIN). For the purposes of this report, please provide data at the organization (as represented by the TIN) level.
Please create your Profile by entering your organization information below. You will be able to edit your profile if there are any changes during the reporting period.
Please enter the Tax Identification Number (TIN) of the organization that received the RHC Testing Program money for which you represent.
[validated answer]
Please enter the name and address of the TIN organization:
[Name Address Line 1 Address Line 2 City State Zip Code]
Please enter the CMS Certification Number(s) – also known as PTAN number(s) – for each RHC associated with this TIN organization:
[6 digit validation]
[Dropdown Menu]
Independent/Freestanding
Provider Based/Hospital Owned
Do you have another CCN/PTAN number?2
Yes [dropdown menu]
No
For what purpose(s) has your TIN organization used or plan to use RHC Covid-19 Testing Funds? (select all that apply)
Building or construction of temporary structures
Leasing of properties
Retrofitting facilities to support COVID-19 testing
Planning for implementation of a COVID-19 testing program
Procuring supplies to provide testing
Training providers and staff on COVID-19 testing procedures
Items and/or services furnished to an individual that results in an order or the administration of COVID-19 testing
Staff time and salary associated with COVID-19 testing
Other (please specify)
Does your TIN organization have a testing location?
Yes
No
Please provide an address for each location your TIN organization is offering testing to patients (if you are providing testing in a temporary structure, such as in the parking lot of the hospital, please provide the most reasonable address for such testing):
[Location 1 Name Address Line 1 Address Line 2 City State Zip Code]
Do you have another testing location?
Yes [validated address]3
No
Step 4-Testing Data
HHS is collecting data on the RHC COVID-19 Testing Program for each month starting with May 2020 until the end of the program.
Testing is defined in the terms and conditions. If your organization does only the specimen collection portion of a test, that counts as a test for the purposes of this report. Testing includes all viral test, antibody tests, and rapid result tests approved under the emergency use authorization (EUA).
How many tests has your TIN organization conducted in the selected month? Provide the most accurate count possible for “# Tests.” If necessary, please estimate to the best of your ability the number of tests in the selected month.4
Month	# Tests	# Positive Tests
May 2020
June 2020
July 2020
August 2020
September 2020
October 2020
November 2020
December 2020
January 2021
February 2021
March 2021
April 2021
Step 5 - Thank You for Reporting
Thank you for reporting your test data. Please remember to report your data each month until instructed otherwise by the Health Resources and Services Administration of the U.S. Department of Health and Human Services, not to exceed a period of two years after the distribution of funds (May 2022).
For more information please see the links below.
Links at bottom of each page:
Frequently Asked Questions (Health Resources and Services Administration): https://www.hrsa.gov/rural-health/coronavirus/frequently-asked-questions
National Association of Rural Health Clinics: www.narhc.org
Rural Testing Relief Fund Terms and Conditions: https://www.hhs.gov/sites/default/files/terms-and-conditions-rural-testing-relief-fund.pdf

Acronym List:
CCN	Centers for Medicare & Medicaid Services Certification Number
PTAN	Provider Transaction Access Number
RHC	Rural Health Clinic
RHC CTR	Rural Health Clinic COVID-19 Testing Report
TIN	Tax Identification Number

1 Automated password recovery process available

2 Ability to add up to 30 CCN/PTAN

3 Ability to add as many locations as necessary

4 Month available at the completion of applicable month

PREDECISIONAL AND UNDER OMB REVIEW