Form 0906-0066 HRSA FORHP COVID-19 Data Report

OMB No.: 0906-XXXX

Expires: MM/DD/YYYY

Small Rural Hospital Improvement Program (SHIP) COVID-19 Testing and Mitigation (CTM) Program Data Report

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of small rural hospitals, number of COVID-19 tests conducted, and the types of allowable SHIP services provided with SHIP American Rescue Plan (ARP) COVID-19 Testing and Mitigation funding. FORHP will use these data to show how SHIP ARP COVID-19 Testing and Mitigation 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/XXXX. This information collection is required to obtain or retain a benefit (FY 2021 American Rescue Plan Act - P.L. 117-2). 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
SHIPCovidReporting.com
Title of Webpage
SHIP COVID-19 Testing and Mitigation Reporting Portal
Step 1 - Splash Page (Eligibility + Privacy Statement)
Introduction
The American Rescue Plan Act of 2021 (P.L. 117-2) provides one-time funding for awards that will be carried out under Section 711 of the Social Security Act (42 U.S.C. 912(b)(5)). Small Rural Hospital Improvement Program (SHIP) state grantees will improve health care in rural areas by using the funding to provide support to eligible rural hospitals to increase COVID-19 testing efforts, expand access to testing in rural communities, and expand the range of mitigation activities. Funded activities include testing education, establishment of alternate testing sites, test result processing, arranging for the processing of test results, and engaging in other activities within the CDC Community Mitigation Framework to address COVID-19 in rural communities.
Public Burden Statement
The purpose of this data collection system is to collect aggregate data on the number of small rural hospitals, number of COVID-19 tests conducted, and the types of allowable SHIP services provided with SHIP ARP COVID-19 Testing and Mitigation funding. FORHP will use these data to show how SHIP COVID-19 Testing and Mitigation Program 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/XXXX. This information collection is required to obtain or retain a benefit (FY 2021 American Rescue Plan Act- P.L. 117-2). 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 SHIPCovidReporting.com and how it will be used.
AUTHORITY: American Rescue Plan Act (Public Law No: 117-2). This page is managed by the National Association of Rural Health Clinics under cooperative agreement G27RH42182 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 SHIP COVID-19 Testing and Mitigation Program. This reporting system does not replace any other reporting requirements that hospitals or state offices of rural health 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 impact of the funding provided to small rural hospitals for COVID-19 testing and mitigation related expenses.
DISCLOSURE: Mandatory. Hospitals that receive SHIP COVID-19 Testing and Mitigation Funds, (or their state offices of rural health) are expected to provide information quarterly.
Please select your state
[List of States]
Click Here to Continue Button
Step 2 – Registration
[IF User selects a state in which recipient hospitals report directly]
Data entry in SHIPcovidreporting.com in your state is managed by each recipient hospital. Please understand that each hospital as represented by their Medicare CCN needs to have one account on SHIPcovidreporting.com per recipient hospital. Click HERE to Register/Login
Registration/Login Page
You must be registered to use this site.
Register Button
If you are already registered, please click on LOGIN button below to sign in to your profile.
Login Button
[Standard 2 factor authentication sign-in/registration]1
[IF User selects a state in which recipient the State Office of Rural Health reports on behalf of its hospitals]
Data entry in SHIPcovidreporting.com in the state of CA is managed by the SHIP Coordinator. If you work at a hospital please connect with your state SHIP program to make sure you are compliant with reporting for the SHIP COVID-19 Testing and Mitigation Program. SHIP Coordinators Please Click HERE to login [Standard 2 factor authentication sign-in]
Step 3 – Profile Found
Profile Found for CCN: XXXXXX Name: XXXXXX Last Updated: MM/DD/YYYY at HH:mm a.m./p.m.- Please click here to continue
Step 4- Profile Screen
Your SHIP CCN Identification Number
[auto populated from registration]
Please select your SHIP organization type:
Critical Access Hospital
Prospective Payment System Hospital
Please enter the name and address of the SHIP organization:
[Name Address City State Zip Code]
Update/Confirm Button
Step 5- Testing and Mitigation Use of Funds Questions
COVID-19 Testing (please select all that apply)
Procure, provide, or process COVID-19 tests (including at-home tests)
Develop and implement strategies for patient testing confidence
Access for community populations to address health and social inequities
Minor alterations and renovations: installing structures, retrofitting to support COVID testing
Leasing property
Plan for implementation of a COVID-19 testing program, including hiring and training of staff, and reporting data
Equipment purchased to support testing
Other activities related to COVID-19 testing (please describe)
COVID-19 Mitigation (please select all that apply)
Develop and implement policies and procedures to keep staff and patients healthy
Maintain healthy operations for staff
Implement strategies to address employee stress and burnout
Investigate COVID-19 cases and conduct contact tracing
Minor alterations and renovations to support mitigation efforts
Use digital technologies to strengthen hospital response to COVID-19
Supporting referrals to testing, clinical service and supports to mitigation strategies
Planning for implementation of COVID-19 mitigation
Training providers and staff on COVID-19 mitigation
Other activities related to COVID-19 (please describe)
Step 4-Testing Data
Reporting Quarters can be reported on when the quarter ends; i.e. you can report Q2 data beginning in Q3. Every field requires an entry, you should enter a 0 for each quarter in which you did not yet need to report data or in which you have no data to report.
Testing is defined as: An in vitro diagnostic test defined in section 809.3 of title 21, Code of Federal Regulations (or successor regulations) for the detection of SARS– CoV–2 or the diagnosis of the virus that causes COVID–19, and the administration of such a test, that— Is approved, cleared, or authorized under section 510(k), 513, 515, or 564 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360(k), 360c, 360e, 360bbb–3); The developer has requested, or intends to request, emergency use authorization under section 564 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360bbb–3), unless and until the emergency use authorization request under such section 564 has been denied or the developer of such test does not submit a request under such section within a reasonable timeframe; Is developed in and authorized by a State that has notified the Secretary of Health and Human Services of its intention to review tests intended to diagnose COVID-19; or Other test that the Secretary determines appropriate in guidance. 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 hospital conducted in the selected quarter? Provide the most accurate count possible for “# of Tests.” If necessary, please estimate to the best of your ability the number of tests in the selected quarter.2 YOU MUST MAKE AN ENTRY IN EVERY FIELD, IF YOU HAVE NO DATA TO REPORT PLEASE ENTER “0” IN THE FIELD.
For CCN: [corresponding CCN #]
Month	# of Tests
Q1 January – March 2021
Q2 April – June 2021
Q3 July – September 2021
Q4 October – December 2021
Q5 January – March 2022
Q6 April – June 2022
Q7 July – September 2022
Q8 October – December 2022
Step 5 - Thank You for Reporting
Thank you for reporting on SHIPcovidreporting.com. Please visit https://www.ruralcenter.org/ship/american-rescue-plan to learn more about the SHIP Covid-19 Testing and mitigation Program.
For more information please see the links below.
Links at bottom of each page:
For more information click on the links below:
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
SHIP COVID Testing and Mitigation https://www.ruralcenter.org/ship/american-rescue-plan
Copyright ©2020 All Rights Reserved OMB Number (0906-0056) Expires 04/30/2021

Acronym List:
CCN	Centers for Medicare & Medicaid Services Certification Number
SHIP	Small Rural Hospital Improvement Program
SHIP CTM	SHIP COVID Testing and Mitigation

1 Automated password recovery process available

2 Month available at the completion of applicable month