HIS 2-A(PT) Permission to Contact

OMB No. 0920-0214: Approval Expires 12/31/2009

HIS-2A(PT)

a. RO Code

FORM
(6-18-2008)

b. FR Code

c. Year

d. Quarter

e. Week

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. CENSUS BUREAU

f. Date of Interview

ACTING AS COLLECTING AGENT FOR THE

Month

Day

Year

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
NATIONAL CENTER FOR HEALTH STATISTICS
NATIONAL CENTER FOR
IMMUNIZATION AND RESPIRATORY DISEASES

2

0

g. Control
Number

PERMISSION TO CONTACT
IMMUNIZATION
PROVIDER FORM

i. Line No.
of child

h. Caseid

NOTICE – Information contained on this form which would permit identification of any individual or establishment has been collected with a guarantee that
it will be held in strict confidence, will be used only for purposes stated for this study, and will not be disclosed or released to others without the consent of
the individual or establishment in accordance with Section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information
Protection and Statistical Efficiency Act (44 USC 3501 note). Public reporting burden of this collection of information is estimated to average about 4
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden to CDC/ATSDR Reports, Clearance Officer; Paperwork Reduction Project (0920-0214), 1600
Clifton Rd., MS D-24, Atlanta, GA 30333.

Permission From Personal Interview

Permission From Telephone Interview

Your permission is important to the work of the Centers for Disease
Control and Prevention (CDC) to determine whether children are
fully immunized.

Your permission is important to the work of the
Centers for Disease Control and Prevention to
determine whether children are fully immunized.

I give CDC and its contractors permission to contact
the provider(s) named in this interview, give the
provider basic information that identifies the child
named below and request that information relevant to
his/her immunization history be sent to the CDC or its
contractors for study purposes only.

Do we have your permission to contact the provider(s)
named in this interview, give the provider basic
information that identifies the child named below and
request that information relevant to his/her
immunization history be sent to the Centers for
Disease Control and Prevention or its contractors?

I understand that all information about my child and
my child’s health care provider is held in strict
confidence. No names of children, doctors, or clinics
will be used in reporting the study results.

You understand that all information about your child
and your child’s health care provider is held in strict
confidence. No names of children, doctors, or clinics
will be used in reporting the study results.
(PARENT/LEGAL GUARDIAN HAS GIVEN ORAL PERMISSION)

We appreciate your cooperation.

Field Representative’s (FR’s) PRINTED NAME:
FR’s (Interviewer’s) First name

PARENT/LEGAL GUARDIAN’S SIGNATURE (in ink):
FR’s (Interviewer’s) Last name

FR’S (INTERVIEWER’S) SIGNATURE (in ink):

PARENT/LEGAL GUARDIAN’S PRINTED NAME
Parent/Legal Guardian’s First name
TODAY’S DATE:
Month

Parent/Legal Guardian’s Last name

Day

Year

2
The above Request Statement is voluntary. There will be no effect on your benefits and no information that
will identify you will be given to any other government or nongovernment agency. This information is
collected under the authority of the Public Health Service Act (Title 42, United States Code, Section 242k).
1. Child’s name

3. Sex

2. Date of birth
Month

Day

Year
Male
Female

0

PERMISSION FORM ID NUMBER