Form 5 PCAs Survey Tool Questions 7-21

16B05 
Dial in: 866‐914‐8382; Participant: 3707732 

COVID‐19 
Information Collection 
Survey Tool Questions for PCAs 

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

1/29/2021 

The goal of this survey is to increase information sharing between Health Centers, PCAs, and the Health 
Resources and Services Administration in order to better support COVID‐19 (Coronavirus) emergency 
response efforts. 
Reminder:  As part of COVID‐19 emergency‐response efforts, we are asking PCAs to follow up with the 
health centers in their State/Territory  that haven’t responded to the online COVID‐19 data collection 
survey to help maximize the response rate. PCAs are asked to fill out their individual survey every two 
weeks, by Thursday, 11:59 PM EST, to supplement information received directly from Health Centers.  
Question 
Number 

Question Field 

Description 

Question 1 

Please enter your email address 

[you@example.com] 

Question 2 

Please select your organization: 

[Select an answer choice 
from the list] 

Question 3 
(a, b, c) 

Question 4 

Question 5 

Key State‐wide Issues/Concerns (Select your 
top five): 
 PPE supplies
 Testing supplies
 Financial stability
 Infrastructure needs (such as technology
or equipment to support operations) 
 Care for specific populations
 Addressing health disparities
 Telehealth/virtual health care
 Workforce
 COVID‐19 vaccine distribution and
administration
 Other (e.g., emerging issues)
How is your organization connected with 
your state/local emergency response efforts 
(e.g., public health department, governor’s 
office), including testing, reopening plans, 
vaccination plans, etc.? Please include any 
changes since your last update. 

[Select top five answers 
that apply from the list; 1 
is required; 2 ‐ 5 are 
optional; may only select 
an issue once]  
[Please briefly describe 
the issue from the State 
perspective] 

[Please describe] 

Are there issues with COVID‐19 vaccine 
confidence, communications, or outreach in 
[Please describe] 
your state? If yes, please identify the specific 
counties (or other local public health 

Answer Field 
[text field] 
Pick List of all 
PCAs 

Pick List 
Multi‐select 
(subcategory 
choices) 
[Free text] 

[Free text] 

Pick List Y/N 
If response is 
Y, then add  
[Free text] 

jurisdictions) and describe the 
circumstances. 

Question 6 

Please provide any additional COVID‐19 
related information, comments, and/or 
needs from HRSA.  

[Please describe] 

[Free text] 

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 and are critical in the national response to COVID-19. These forms
provide HRSA with the information essential for analyzing health center progress, challenges, and needed technical assistance around COVID-19. 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
paperwork@hrsa.gov.