Provider Forms

Attachment T 7317-IMMCL – Director’s Immunization Cover Letter for Providers

FROM THE DIRECTOR

US CENSUS BUREAU

Dear [Name of SSS#1],

[Name of SSS#2],

[Name of SSS#3]:

We received your signed Immunization Survey Special Sworn Status forms for the special study of the National Immunization Survey. 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. You can help us at this time by completing the enclosed Immunization History Questionnaire(s) (IHQ) for the child(ren) whose names and birth dates appear on them, whether or not you were the provider of the immunizations.

Please complete the enclosed IHQ(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 mail/fax toll-free to:

U.S. Census Bureau

Attention SPB/DSPU/64C,

1201 E 10th Street,

Jeffersonville, IN 47132-0001

FAX: 1–888–595–1338

To protect the identity of the children in this study under the Census Bureau’s Title 13 requirements, please do the following:

• Return the parent/guardian’s consent form to the Census Bureau along with the completed questionnaire in the postage-paid envelope OR destroy both the consent form and hard copy of the questionnaire if you fax the IHQ.

• Use the HIPAA Accounting of Disclosure documentation provided by the Census Bureau for your HIPAA recordkeeping. 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.

• An explanation of the steps to take to maintain the confidentiality of the children in this study is included in this packet. This is similar to information mailed to you with the Immunization Survey Special Sworn Status form.

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,

[Electronic Signature] [Electronic Signature]

[Director’s Name] Anne Schuchat, M.D.

Director, U.S. Census Bureau Rear Admiral, United States Public Health Service

Director, National Centers for Immunization and Respiratory Diseases

Enclosures:

Documentation of Consent(s)

Immunization History Questionnaire(s)

HIPAA Accounting of Disclosure

Explanation of the Immunization Survey Special Sworn Status

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