BC-1759 (P) Immunization Study Special Sworn Status Form

OMB No. XXXX-XXXX
Form BC-1759 (P)
(00-00-2009)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. CENSUS BUREAU

IMMUNIZATION SURVEY SPECIAL SWORN STATUS
Instructions: A separate form must be completed by each person who will have access to the data sent by
the U.S. Census Bureau and/or who will be completing the data collection forms for the National
Immunization Survey.
PART A - PRACTICE/CLINIC/HOSPITAL INFORMATION
1. Practice/Clinic/Hospital name
2. Practice/Clinic/Hospital address
3. Practice/Clinic/Hospital telephone number (Including area code)
PART B – CONTACT IDENTIFICATION
Please provide your name and contact information.
1. Name (Last, First, Middle)

□ By checking this box, I agree
that I am 18 years old or older

2. Contact telephone number (Including area code and extension)
3. Position/Job title
PART C – WAIVER OF COMPENSATION
I, the undersigned, offer my services to the U.S. Census Bureau as Special Sworn staff on a voluntary basis
without compensation.
PART D – OATH OF NONDISCLOSURE
By signing below, I, ___________________________, certify, under penalty of perjury, that I will keep
the identity of any patients related to this survey confidential. I will not disclose information that might
identify a person in the National Immunization Survey Evaluation Study to any person other than those with
Census Bureau Special Sworn Status and direct involvement in this study. I also understand that under Title
13, U.S.C. section 214 and Title 18, U.S.C.3551, et. seq., the penalty for unlawful disclosure is a fine of not
more than $250,000 or imprisonment for not more than 5 years, or both.
_______________________________________________________

(Signature of appointee)

___________________________

(Date)

Census Bureau
Office Use Only