Email Invitation

Form Approved

OMB No: 09201026

Exp. Date: 07/31/2017

NOTE TO REVIEWER: The consumer access portal has been implemented in 5 states. The portal has a different name in each state. The text that appears in brackets [ ] will be programmed according to the state of residence of the individual.

Dear [RESPONDENT NAME]:

Within the past 2 weeks you activated your account for [PROGRAM NAME], to access immunization records online for yourself or a family member(s). Audacious Inquiry in collaboration with the Centers for Disease Control and Prevention is conducting a brief survey of individuals who have registered for [PROGRAM NAME] to learn more about their experience with using the system. Responses to this survey will help us evaluate and improve [PROGRAM NAME]. The survey should take approximately 10 minutes to complete. Your participation is completely voluntary, and your responses will be kept secure. No personally-identifying information will be collected and your responses will be anonymous.

If you agree to participate in this survey, please click on the following link to complete the survey: [SURVEY WEB LINK]. Please remember to click the “submit” button at the end of the survey to ensure that you will not receive further reminders about this survey.

If you have questions or concerns about this survey, please contact [CONTACT NAME].

Thank you for your participation!

Sincerely,

Shannon Stokley, MPH

Associate Director for Science

Immunization Services Division

Centers for Disease Control and Prevention

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333; ATTN: PRA (09201026)