Attachment 4 Cover for NIS Teen Immunization History Questionnaire
The following statement will be in the packet mailed to providers and will be added to the form when forms are reprinted.
Notice - Public reporting burden for this collection of information is estimated to average 5 minutes per response, including 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 burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-24, Atlanta, GA 30333, ATTN: PRA (0920-0212).
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).
| File Type | application/msword |
| File Title | Attachment 2 Cover for Permission to Contact Immunization Provider Form |
| Author | Howard Riddick |
| Last Modified By | Howard Riddick |
| File Modified | 2008-08-01 |
| File Created | 2008-07-28 |