Cover sheet for Permission to Contact

Attachment 2 Cover for Permission to Contact Immunization Provider Form

The following statement will replace the first sentence in the box on the form when forms are reprinted:

Assurances of Confidentiality – All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).