Provider Forms

DC

7317-IMMRL
(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

A packet of materials from the U.S. Census Bureau on behalf of the Centers for Disease Control and Prevention
was sent to your practice recently with a request to complete and return the Immunization History
Questionnaire(s) for the child(ren) whose name appears on the enclosed form.
If you have returned the requested information, thank you for your participation. If you have not returned the
Immunization History Questionnaire(s), please complete the enclosed questionnaire(s) and fax it or mail it in the
enclosed prepaid envelope to the U.S. Census Bureau with the vaccination information. As these medical
documents are confidential, if sending a 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.
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
Enclosures:

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

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