Provider Forms

7317-SSSII A

Steps for filling out the Special Sworn Status form

The Census Bureau never releases the names or other identifying information of people in our surveys. We protect this information as part of maintaining the public trust and confidence in our work. As you help us collect immunization data for this survey we need you to protect the children’s identities as the Census Bureau does. Please follow the steps below to complete the attached Immunization Survey Special Sworn Status form, BC-1759 (P).

Step 1. Verify that the practice/clinic/hospital name, address, and telephone number in Part A of the attached form are correct. If necessary, make corrections directly on the form.

Step 2. Complete Part B of the form. Be sure to fill in your full name,

contact telephone number, and position/job title.

Step 3. Check the box in Part B to confirm that you are 18 years old or older.

Step 4. Read Part C of the form.

Step 5. Complete Part D of the form. Be sure to fill in your name and sign and date the form. 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 the National Immunization Survey (NIS).

Step 6. Please return your completed form BC-1759 (P) within seven days, using the postage-paid envelope provided. After the Census Bureau receives your completed form you will be mailed an Immunization History Questionnaire (IHQ) to fill out for a child in your practice, along with a permission form from the child’s parent/guardian, which gives consent for his/her involvement in the study.

Additional information about the purpose of Special Sworn Status and protecting the identity of children in the study can be found on the back of this sheet.

7317-SSSII B

Purpose of the Immunization Survey

Special Sworn Status

Since the U. S. Census Bureau is conducting this special study of the National Immunization Survey, the names of the children selected for the survey are confidential under Title 13, Section 9 in the United States Code. Section 23(c) of Title 13 provides authority for the Census Bureau to swear in people to assist the Census Bureau in performing its duty. Anyone who will see the children’s names on an Immunization History Questionnaire (IHQ) or complete the immunization questionnaires must first obtain Special Sworn Status by completing an Immunization Survey Special Sworn Status form, BC-1759(P). By signing the Special Sworn Status form (enclosed), you agree not to disclose that your patient(s) was included in the National Immunization Survey to anyone who has not signed one of these forms.

Steps to Protect the Identity of Children in the Study

Step 1. When your office receives the Immunization History Questionnaires for patients in your practice, it will be labeled, “Confidential, To Be Opened By Addressee(s) Only,” and will be addressed ONLY to the people in your office who have obtained Special Sworn Status.

Step 2. Please keep all IHQs that contain a child’s name and date of birth and any parental consent documents in a locked, secure location, accessible only to people with Special Sworn Status. This location could be a lockable desk drawer or lockable office.

Step 3. 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. The Census Bureau will provide you with specific HIPAA Accountings of Disclosure that have been developed for this survey. 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.

Step 4. After someone with Special Sworn Status fills out the IHQs your office may receive, 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 destroy the consent documents along with any hard copy IHQs in your office once the information has been submitted. The only documentation from this study that should remain at your office is the HIPAA Accountings of Disclosure that the Census Bureau will provide for your office.

Step 5. Should another person in your office need to know the identity of children in the survey, they will need to complete and return to the Census Bureau an Immunization Survey Special Sworn Status form prior to viewing 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, however the signature on each form must be original.

Step 6. In the event that someone with Special Sworn Status leaves the employment of your current office, he or she should hand over all materials related to the survey to another member of the office with Special Sworn Status. If no one else has Special Sworn Status, please return all IHQs and consent documents to the Census Bureau.