7317-110E Permission to Contact Immunization Provider - English

OMB No. XXXX-XXXX Approval Expires XX/XX/XXXX
FORM 7317-110E
(6-1-2009)

a. RO Code

U.S. DEPARTMENT OF COMMERCE

b. FR Code

f. Date of Interview

Economics and Statistics Administration

c. Year

Month

Day

U.S. CENSUS BUREAU

d. Quarter

Year

2

ACTING AS DATA COLLECTION AGENT FOR THE
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases

e. Week

0

g. Control number

PERMISSION TO CONTACT
IMMUNIZATION
PROVIDER

h. Case ID

i. Line No.
of child

NOTICE – The U.S. Office of Management and Budget (OMB) approved this survey and gave it OMB control Number XXXX-XXXX.
Displaying this number shows that the Census Bureau is authorized to conduct this survey. Please use this number in any
correspondence concerning this survey.

Permission from Telephone Interview
Your permission is important to the work of the U.S. Census Bureau and the Centers for Disease
Control and Prevention (CDC) to determine whether children are fully vaccinated.
Do we have 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 U.S. Census Bureau?
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.
Mark (X) Box If Parent/Legal Guardian Has Given Oral Permissiol To Contact Immunization Provider(s)
First name
Last name
Supervisor’s PRINTED NAME:

Supervisor’s Signature (in ink):
Permission from Personal Interview
Your permission is important to the work of the U.S. Census Bureau and the Centers for Disease Control and
Prevention (CDC) to determine whether children are fully vaccinated.
I give the U.S. Census Bureau permission to contact the provider(s) named in this interview, to give the provider
basic information that identifies the child named below, and to request that information relevant to his/her
immunization history be sent to the U.S. Census Bureau for study purposes only.
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.
We appreciate your cooperation.
PARENT/LEGAL GUARDIAN’S SIGNATURE (in ink)
PARENT/LEGAL GUARDIAN’S PRINTED NAME:
TODAY’S DATE:

Parent/Legal Guardians’s First name:

Month

Day

Year

Parent/Legal Guardians’s Last name:

2

0

The law authorizes the Census Bureau to collect information for this survey (Title 13, United Stataes Code (U.S.C.), Section 182).
Section 9 of this law requires us to keep all information about you and your household strictly confidential. The Census Bureau will
use this information only for statistical purposes. Everyone who has access to your responses is subject to a prison term, a fine up
to $250,000, or both, if any information is revealed that identifies you or your household.

1. Child’s name
2. Date of birth

PERMISSION FORM ID NUMBER

Month

Day

Year

3. Sex
Male

USCENSUSBUREAU

Female