Various Pretesting Activities (see attached list)

A ttachment O - 7317-SSSII – Explanation of the Immunization Survey Special Sworn Status

Explanation of the Immunization Survey

Special Sworn Status

• A survey of immunizations for children between the ages of 19-35 months is being conducted by the U. S. Census Bureau on behalf of the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services.

• Section 23(c) of Title 13 in the United States Code provides authority for the Census Bureau to swear in people to assist the Census Bureau in performing its duty.

• To help the Census Bureau protect the confidentiality of the children selected for this survey, health care staff who receive information on the children and provide the immunization records for the children must complete an Immunization Survey Special Sworn Status form, BC-1759 (P).

• By signing the enclosed form, you agree not to disclose that your patient(s) was a subject of this study to anyone who has not signed a Special Sworn Status form regarding this study.

Steps to Protect Confidentiality with Special Sworn Status

• Keep all Immunization History Questionnaires (IHQs) and consent documents in a locked, secure location accessible only by others with Special Sworn Status.

• Do not put any documentation (or copies) related to the survey in the child(ren)’s medical records, including the consent documents, IHQs, and the HIPAA Accountings of Disclosure. If it is required by the policies of your specific office to place disclosure documentation in the child(ren)’s medical record, please call the Census Bureau at 1-XXX-XXX-XXXX to request a disclosure form specially prepared for this study.

• Return the parent/guardian consent documentation to the Census Bureau with the completed questionnaires in the postage-paid envelope. It is not necessary to keep the consent documents in your office. If it is more convenient for you to fax the IHQ/vaccination information you may also destroy the consent documents along with any hard copy IHQs in your office once the information has been submitted.

• Anyone in your office who receives or is privy to information about the child(ren) in the survey will need Special Sworn Status. Should another person in your office require access to this survey’s confidential information, they will need to complete an Immunization Survey Special Sworn Status form prior to receiving access to this information. Please contact the Census Bureau at 1-XXX-XXX-XXXX for additional Special Sworn Status forms or you may make a copy of any blank forms you already have on hand.

• In the event that you leave the employment of your current office, hand over all materials related to the survey to another member of the office with Special Sworn Status. If no one is available, please return all IHQs and consent documents to the Census Bureau.