Provider Forms

7317-SSSII

Explanation of the Immunization Survey
Special Sworn Status
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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.

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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.

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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).

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

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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 1-888-595-1339 to request a disclosure form specially prepared for
this study.

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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.

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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
1-888-595-1339 for additional Special Sworn Status forms or you may make a copy of any blank forms
you already have on hand.

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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.