Various Pretesting Activities (see attached list)

Form BC-1759 (P) OMB. No. 0607-0725 Approval expires 8/31/2010	U.S. DEPARTMENT OF COMMERCE Economics and Statistics Administration U.S. CENSUS BUREAU
IMMUNIZATION SURVEY SPECIAL SWORN STATUS
Instructions: A separate form must be completed by each person who will have access to the data sent by the U.S. Census Bureau and/or who will be completing the data collection forms for the National Immunization Survey.
PART A - PRACTICE/CLINIC/HOSPITAL INFORMATION
1. Practice/Clinic/Hospital name
2. Practice/Clinic/Hospital address
3. Practice/Clinic/Hospital telephone number (Including area code)
PART B – CONTACT IDENTIFICATION
Please provide your name and contact information.
1. Name (Last, First, Middle)			□ By checking this box, I agree that I am 18 years old or older
2. Contact telephone number (Including Area Code and extension)
3. Position/Job title
PART C – WAIVER OF COMPENSATION
I, the undersigned, offer my services to the U.S. Census Bureau as Special Sworn staff on a voluntary basis without compensation.
PART D – OATH OF NONDISCLOSURE
By signing below, I, ___________________________, certify, under penalty of perjury, that I will keep the identity of any patients related to this survey confidential. I will not disclose information that might identify a person in the National Immunization Survey Evaluation Study to any person other than those with Census Bureau Special Sworn Status and direct involvement in this study. I also understand that under Title 13, U.S.C. section 214 and Title 18, U.S.C.3551, et. seq., the penalty for unlawful disclosure is a fine of not more than $250,000 or imprisonment for not more than 5 years, or both.
_______________________________________________________ (Signature of appointee)		___________________________ (Date)
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