DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Centers for Disease Control and Prevention

National Center for Immunization 

and Respiratory Diseases

1600 Clifton Road, NE

Mail Stop E-05

Atlanta, Georgia 30333

FROM THE DIRECTOR, NATIONAL CENTER FOR IMMUNIZATION AND RESPIRATORY 

DISEASES

The U.S. Public Health Service is committed to reaching the Healthy People 2030 target to increase 

immunization rates and reduce preventable infectious diseases. To measure progress toward this target,

the Centers for Disease Control and Prevention (CDC) is conducting the National Immunization Survey

Provider Record Check Study. This study collects and reports the most complete information available on the

current vaccination levels of preschool children and adolescents for each state.

This study includes supplementing household reports of immunization collected by telephone interviews with the 

immunization information from health care provider offices. We are requesting information from all medical 

providers on vaccinations given and the dates of vaccination for children or adolescents whose parent or guardian 

participated in the telephone survey. The type of vaccine, the number of vaccinations, and the dates of vaccination 

will be used to estimate vaccination levels and progress toward Healthy People 2030 objectives. The protected 

health information requested is the minimum necessary to accomplish the objectives of the study.

The parent/guardian has agreed to participate in this study, and has verbally consented during the telephone 

interview to allow us to obtain immunization information from your records. Enclosed is a copy of the form(s) 

used to document the parent/guardian verbal consent to disclose information from their child(ren)'s immunization 

record(s). Pursuant to the document of consent, we would appreciate the completion of the enclosed 

Immunization History Questionnaire(s) for the named child(ren) whether or not you were the provider of the 

immunizations.

Please be assured that there are several ways that the Privacy Rule (as mandated by the Health Insurance 

Portability and Accountability Act (HIPAA)) allows you to participate in the NIS. Disclosures of patient data are 

permitted for public health surveillance purposes – which applies to this survey. In addition, a Privacy Board at

the Centers for Disease Control and Prevention has reviewed this study. We invite you to visit our respondent

website (www.cdc.gov/nchs/nis.htm) for information regarding the survey including important policies and 

procedures regarding confidentiality and meeting the HIPAA Privacy Rule requirements. Additional information 

regarding HIPAA is available at the following website:

http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm.

This study is authorized by Section 306 of the Public Health Service Act and The National Childhood Vaccine 

Injury Act of 1986. The information you supply will be treated confidentially, as specified by law in Section

308(d) of the Public Health Service Act. The information will be used for statistical purposes only; no 

information that could identify you, your practice, your facility, the child, or the child's family will be released. 

Although your participation is voluntary, we hope that you will choose to participate.

http://www.cdc.gov/vaccines/
You may participate by completing the enclosed questionnaire(s) and faxing or mailing it in the enclosed prepaid 

envelope to NORC at the University of Chicago with the vaccination information. As these medical documents are 

confidential, if sending a fax please take extra care to dial the correct toll-free fax number. Mail or fax to:

NORC at the University of Chicago

National Immunization Survey

55 E Monroe Street, FL 19

Chicago, IL 60603

FAX: (866) 324-8659

To assist you with HIPAA recordkeeping, we have provided you with a Documentation Notice for HIPAA 

Accounting. This document should be placed in each child’s record.

In developing this package, efforts have been made to consolidate multiple requestsfor immunization records for 

children in your practice. However, as the survey collects information continuously throughout the year, you may 

receive additional requests for immunization information on other children for whom you provide medical care.

Please review the following links for further information: 

MMWR article on vaccination coverage for children:

https://www.cdc.gov/mmwr/volumes/72/wr/mm7244a3.htm

MMWR article on vaccination coverage for teens:

https://www.cdc.gov/mmwr/volumes/72/wr/mm7234a3.htm

Information about vaccinations of children and adolescents:

http://www.cdc.gov/vaccines

Healthy People 2030 objectives related to immunization and infectious diseases:

https://health.gov/healthypeople/objectives-and-data/browse-objectives

If you have any questions or comments about the enclosed material, or the records being requested, please call

1-800-817-4316. If you would like additional information about the National Immunization Survey, please call 

Dr. Laurie Elam-Evans at (404) 718-4838 with the Centers for Disease Control and Prevention. Your

participation in the National Immunization Survey Provider Record Check Study is greatly appreciated.

Sincerely yours,

 Demetre Daskalakis, MD, MPH

Director, National Center for Immunization and Respiratory Diseases

Enclosures:

Roster of Immunization History Questionnaires issued

Immunization History Questionnaire(s) (for each child/adolescent)

Documentation of Telephone Consent (for each child/adolescent)

NIS Documentation Notice for HIPAA Accounting (for each child/adolescent)

Frequently Asked Questions about the HIPAA and the NIS Institutional Review Board Approval

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