Household Forms

Date

Dear ,

One of our interviewers contacted you recently regarding a survey that the U.S. Census Bureau is conducting for the Centers for Disease Control and Prevention (CDC), called the National Immunization Survey. Because your participation is important, I am writing to ask for your much needed assistance in this survey.

We understand that parents or guardians might have some concerns about sharing their children’s immunization records. Other than contacting your child’s immunization provider, we will not share any information that could identify you, your child, or your child’s medical history. We are conducting this survey under the authority of Title 13, United States Code, Section 8, which means your answers to questions are kept confidential. In addition, you do not need to answer questions or report information that you feel is too personal.

For more information, we have included frequently asked questions about the National Immunization Survey on the back of this letter. Please feel free to contact us by phone at

1-888-595-1340 if you would like to discuss your specific concerns.

We hope this letter addresses any concerns, and that you will strongly consider participating in the survey when we contact you again.

Thank you,

Evelyn A Chandler

Branch Chief, Tucson Telephone Center

U.S. Census Bureau

National Immunization Survey – Evaluation Study

Frequently Asked Questions

How long will this survey take?

It will take approximately 28 minutes to complete the interview.

Why can’t you contact somebody else?

Your household was scientifically selected to participate in this study and represents many

others in your community. Without your help, your community may not be adequately

represented in the results of the survey.

How are the data used?

Although childhood vaccination rates are at an all-time high of 90%, many children still do

not have all of their shots. In response, the Department of Health and Human Services

wants to improve immunization services while lowering the cost of vaccines. Local, state,

and federal health officials need the results of this survey to help achieve those goals.

Data are collected from households with children between the ages of 19 and 35 months

living in the United States at the time of the interview. These data are used to analyze

vaccination levels among young children in the US, to identify groups at risk of

vaccine-preventable diseases and to evaluate the effectiveness of programs designed to

increase vaccination coverage.

The results of this survey also help local, state, and federal health officials understand how

to improve health care services for all children. Therefore, some households may be asked

questions about the types of health services their children need or use.

What confidential protection do I have?

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 child, or the child’s medical history. The information collected will be used

for statistical purposes only. Although your participation is voluntary, we hope that you will

choose to participate in this very important study.

What if I have comments about this survey?

If you have comments about the time estimate or any other aspect of this survey, please

send them to Paperwork Project 0607-####, U.S. Census Bureau, 4600 Silver Hill Road,

AMSD & 3K138, Washington, DC 20233. You may email comments to

Paperwork@census.gov; use “Paperwork Project 0607-####” as the subject. The approval

number from the Office of Management and Budget (OMB) is 0607-#### and it will expire

on Month/Date/Year. Without this approval from the OMB, the Census Bureau could not

conduct this survey.