Contact Information Verification

Attachment B.1: Contact Information Verification

Form Approved

OMB No. 0920-1030

Exp. Date 04/30/2020

NOTICE – Public reporting burden for the contact verification is estimated to average 5 minutes per response. 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1030).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf, of the government.

VERIFY CONTACT INFORMATION

• Hello, my name is ___________________with RTI International, representation the National Center for Health Statistics. I have some information that I would like to mail to the following state government representative [name]. May I please verify this person’s name and title?

• I have the name of this state government representative as ______________________ SPELL IF NECESSARY. Is this correct?

• I have the address of the state government representative as _______________________. Is this correct? Is there a separate mailing address you would like to give me?

• The number I called is [xxx-xxx-xxxx]. Is this the correct number to reach ______________? REPEAT TO VERIFY

• What is [state government representative’s] email address? SPELL ALOUD TO VERIFY.

• Thank you. I will put this information in the mail within 2 business days. Have a good day. Good bye.

1