Provider Forms

DC

7317-IMMCL
(4-2009)

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
Dear
We received your signed Special Sworn Status forms for the National Immunization Survey (NIS) Provider Record
Check Study. The U.S. Census Bureau, along with the Centers for Disease Control and Prevention (CDC), thank you for
assisting us in this very important study.
The parent/guardian has agreed to participate in this study, and has verbally consented during the telephone interview
or in person to allow us to obtain immunization information from your records. Enclosed is a copy of the form(s) used to
document the parent/guardian verbal or written consent to disclose the information from their child(ren)’s immunization
records. Pursuant to the document of consent, we would appreciate the completion of the enclosed Immunization
History Questionnaire(s) for the named child(ren) whether or not you were the provider of the immunizations.
Please complete the enclosed questionnaire(s) with the vaccination information and fax it or mail it in the enclosed
postage-paid envelope to the U.S. Census Bureau. As these medical documents are confidential, if sending by fax
please take extra care to dial the correct toll-free fax number.
Mail all completed forms in the enclosed prepaid envelope or fax to:

U.S. Census Bureau
Attention SPB/DSPU/64C,
1201 E 10th Street,
Jeffersonville, IN 47132-0001
Toll-free fax: (1–888–595–1338)
To protect the identity of the children in this study, please also destroy the parent/guardian’s consent documentation or
return the consent documentation to the Census Bureau with the completed questionnaires in the postage-paid
envelope. An explanation of the steps to take to maintain the confidentiality of the children in this study is included in
this packet.
To assist you with HIPAA recordkeeping, we have provided you with a HIPAA Accounting of Disclosure. In order to
protect the confidentiality of the children in this study under the Census Bureau’s Title 13 requirements, it is important
for you to use the documentation provided by the Census Bureau. Should your office require documentation be placed
in each child’s medical record please call the Census Bureau to request a form specially prepared for this study.
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.
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.

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 Disease

Enclosures:
Documentation of Consent(s)
Immunization History Questionnaire(s)
HIPAA Accounting of Disclosure
Explanation of the Immunization Survey Special Sworn Status
Business Reply Envelope

USCENSUSBUREAU
Helping You Make Informed Decisions

www.census.gov