Provider Forms

7317-SSSRL
(4-2009)

DC

UNITED STATES DEPARTMENT OF COMMERCE
Economics and Statistics Administration

U.S. Census Bureau
Washington, DC 20233-0001
OFFICE OF THE DIRECTOR

FROM THE ACTING DIRECTOR
U.S. CENSUS BUREAU
On behalf of the Centers for Disease Control and Prevention (CDC), the U.S. Census Bureau
sent a packet of materials to your practice recently with a request to complete and return a
confidentiality form to help the Census Bureau conduct a special study of the Provider Record
Check component of the National Immunization Survey (NIS).
The U.S. Public Health Service is committed to reaching the Healthy People 2010 objective
that at least 90 percent of children in the United States complete their primary vaccination
series by their second birthday. To measure progress toward this goal, the CDC conducts the
National Immunization Survey. One component of this survey is the Provider Record Check
Study. This study collects and reports the most complete information available on the current
vaccination levels of preschool children for each state.
The Census Bureau is conducting a special study of the Provider Record Check component of
the National Immunization Survey for the CDC to measure a new sampling methodology that
may improve the coverage of eligible children. While your office or clinic may have participated
in this important survey in the past, we ask for your help by making it possible to test these
new methods and determine whether they result in improvements to the survey.
We are requesting information from all medical providers on vaccinations given and the dates
of vaccination for children 19 through 35 months of age whose parent or guardian participated
in the telephone survey. The type of vaccine, the number of vaccinations, and the dates of
vaccination will be compared with information obtained from the child’s or children’s parent or
guardian in the survey. The protected health information requested is the minimum necessary
to determine the vaccination status of children in the survey.
If you have returned the requested information, thank you for your participation. If you have
not returned the requested information, please complete the Immunization Survey Special
Sworn Status form(s) for each person who will have access to the patient information sent by
the Census Bureau. Please see the back of the letter for more information about the Special
Sworn Status form.
For your convenience, we have enclosed two more copies of the forms and a postage paid
envelope. Mail all completed forms in the enclosed prepaid envelope to:
U.S. Census Bureau
Attention SPB/DSPU/64C,
1201 E 10th Street,
Jeffersonville, IN 47132-0001
Your participation is critical to the success of this study. It is important that we receive your
completed forms as soon as possible, so that we have time to send the Immunization History
Questionnaire(s) for you to complete for the child(ren) participating in this study. If you have
any questions or comments about the enclosed material, or the records being requested,
please call 1-888-595-1339. Your participation in the National Immunization Survey Provider
Record Check Study is greatly appreciated.

USCENSUSBUREAU
Helping You Make Informed Decisions

www.census.gov

This Immunization Survey Special Sworn Status form gives you authorization to help the
Census Bureau in performing its duty and protects the confidentiality of the children selected
for this survey. By signing this form you agree to keep the identity of patients involved in this
study confidential. An explanation of the steps to take to maintain this confidentiality is
attached to each form. Please note that a separate form (BC-1759(P)) must be completed by
each person who will have access to the data sent by the Census Bureau and/or who will be
completing the questionnaire for this survey. Copies of the form can be made if additional
forms are needed; however, the signature on each form must be original. Furthermore, for
your convenience the information in Part A of this form for the Practice/Clinic/Hospital has
been preprinted.
Please be assured that there are several ways that the Privacy Rule (as mandated by the Health
Insurance Portability and Accountability Act (HIPAA)) allows you to participate in the NIS.
Disclosures of patient data are permitted for public health surveillance purposes. In addition, a
Privacy Board at the CDC has reviewed this study. Furthermore, a parent or guardian has given
verbal authorization for the release of the child’s immunization history to us. Documentation of this
verbal consent will be included in the request for immunization data. We invite you to visit the CDC
respondent website (http://www.cdc.gov/nis) for information regarding the survey, including
important policies and procedures regarding confidentiality and meeting the HIPAA Privacy Rule
requirements. Additional information regarding HIPAA is available at the following website:
http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/publichealth/index.html.
The Census Bureau will provide you with all of the documentation needed for accounting purposes.
This survey is authorized by Title 42, United States Code, Sections 306 & 2102(a)(7) of the
Public Health Service Act and by The National Childhood Vaccine Injury Act of 1986. Legal
authorization for the Census Bureau to conduct the survey is granted by Title 13, United
States Code, Section 8. The information you provide will be treated confidentially, as specified
by law in Section 9 of Title 13. We will not release any information that could identify you, your
practice, your facility, the child, or the child’s family. The information collected will be used for
statistical purposes only. Although your participation is voluntary, we hope that you will choose
to participate in this very important study.
Thank you for your cooperation in this most important matter.
Sincerely,

Thomas L. Mesenbourg
Acting Director
U.S. Census Bureau

Anne Schuchat, M.D.
Rear Admiral, United States Public Health Service
Director, National Center for Immunization and
Respiratory Diseases

Enclosures:
Immunization Survey Special Sworn Status Forms (2)
Explanation of the Immunization Survey Special Sworn Status (2)
Frequently Asked Questons about the HIPAA and the NIS
Business Reply Envelope

7317-SSSRL