Form 1 HC COVID-19 Vaccine Prgrm Conditions of Participation Ag

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

HRSA Health Center COVID-19 Vaccine Program
Conditions of Participation Agreement
To ensure our nation's underserved communities and those disproportionately affected by COVID-19 are equitably vaccinated
against COVID-19, the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention
(CDC) are launching the HRSA Health Center COVID-19 Vaccine Program to directly allocate COVID-19 vaccine to HRSAsupported health centers.
HEALTH CENTER IDENTIFICATION
Health center legal name: _____________________________________
Health Center Program grant or look-alike number: ________________________
Health center telephone number: ______________________________

Email: ___________________________________

Health center address: ____________________________________________________________________________________
This HRSA Health Center COVID-19 Vaccine Program Conditions of Participation Agreement is between the participating health
center and the Health Resources and Services Administration (HRSA). This Program will provide COVID-19 vaccine, constituent
products, and ancillary supplies at no cost directly to health centers participating in the HRSA Health Center COVID-19 Vaccine
Program. Participation in this Program does not guarantee continued shipment or any particular number of vaccine doses. This
agreement shall govern all COVID-19 vaccination activities at all health center sites that receive COVID-19 vaccine through the
HRSA Health Center COVID-19 Vaccine Program. By signing this agreement, you agree to adhere to each of the stated
requirements. Participation in this Program is voluntary and may be terminated at any time and for any reason by the health
center or HRSA.
AGREEMENT REQUIREMENTS
To participate in the Program, the health center agrees to:
1) Enrollment in and compliance with the CDC COVID-19 Vaccination Program
a. Enroll in the CDC COVID-19 Vaccination Program to receive and administer COVID-19 vaccine, constituent
products, and ancillary supplies at no cost.
b. Comply with all related conditions in the CDC COVID-19 Vaccination Program Provider Agreement.
2) Accurate completion and approval of the HRSA Health Center COVID-19 Vaccine Program Readiness Assessment
a. Certify that the health center has a policy and procedure for ensuring that staff who administer the COVID-19
vaccine comply with all requirements set forth in the CDC COVID-19 Vaccination Program Provider Agreement.
b. Identify the health center’s current COVID-19 vaccine allocation (amount, schedule, etc.) from a state/jurisdiction
source.
c. Identify a vaccine coordinator at each service site who will be responsible for receiving vaccine shipments, ensuring
storage at required temperatures, monitoring storage unit temperatures, managing vaccine inventory, etc.
d. Identify the health center service site locations to receive the COVID-19 vaccine shipments.
e. Certify that the health center has systems in place to schedule and manage COVID-19 vaccination appointments
and reminders consistent with CDC COVID-19 Vaccination Program Provider Agreement.
3) Data reporting
a. Establish required user accounts and two points of contact to ensure access to critical Program information via the
HRSA Health Center COVID-19 Vaccine Program Online Community.
b. Respond to all data reporting elements in weekly HRSA Health Center COVID-19 survey and the addendum by the
requested deadline.

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

c.

Comply with all state, local and federal required data reporting requirements.

4) Other requirements
a. Follow priority guidelines determined by the health center site’s state/jurisdiction in administering COVID-19
vaccines.
b. Administer COVID-19 vaccines provided through the Program to established health center patients and other
individuals who present for such services (i.e., new patients) as capacity permits.
c. Ensure timely administration of all COVID-19 vaccine doses received through the Program.
AUTHORIZED ORGANIZATION REPRESENTATIVE
By signing this agreement, the health center agrees to adhere to each of the above-stated requirements. The Health Center
must sign this agreement to receive distribution of COVID-19 vaccine through the HRSA Health Center COVID-19 Vaccine
Program. This agreement may be terminated at any time by the Health Center or HRSA.
Name of Authorized Representative ____________________________________________
Title/Position: __________________________________________
Email: _____________________________

Phone Number: _____________________

Signature: _____________________________________________

Date: ______________________________

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, costeffective 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 paperwork@hrsa.gov.

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