Form 1 HRSA FORHP COVID-19 Data Report 12.18.2020

OMB No.: 0906-0056

Expires: 04/30/2021

Rural Health Clinic COVID-19 Testing Program Data Report (RHC CTR)

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 0906-0056 and it is valid until 04/30/2021. 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 0906-0056 and it is valid until 04/30/2021. 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: Mandatory. If you kept the RHC COVID-19 Testing Funds, RHCs are expected to provide information monthly.
Eligibility
Did you or your organization (as represented by a tax identification number (TIN)) receive funds for COVID-19 testing through the RHC COVID-19 Testing Program?
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
*NEW USERS ~ please fill out this form and then submit and that will take you to the monthly testing data entry.*
*RETURNING USERS ~ please update and/or confirm the information on this page and submit to proceed to the monthly testing data entry.*
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. The website only accepts one TIN organization per account. Individuals who represent multiple TIN organizations will need to create additional accounts with separate email addresses.
Please enter the Tax Identification Number 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:
CMS # [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 Program funds? (select all that apply)
My TIN Organization has not spent any portion of the RHC Testing Program Fund
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 enter the name and address of any/all testing location(s) your TIN organization operates. (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 “# of Tests.” If necessary, please estimate to the best of your ability the number of tests in the selected month.4 YOU MUST MAKE AN ENTRY IN EVERY FIELD, IF YOU HAVE NO DATA TO REPORT PLEASE ENTER “0” IN THE FIELD.
For TIN: [corresponding TIN #]
Month	# of 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:
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
Rural Testing Relief Fund Terms and Conditions: https://www.hhs.gov/sites/default/files/terms-and-conditions-rural-testing-relief-fund.pdf
Copyright ©2020 All Rights Reserved OMB Number (0906-0056) Expires 04/30/2021

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