Coversheet

Attachment J. Part 1. 2009 NHAMCS-101 – Cover sheet

This form (NHAMCS 101) will show the 2009 burden, which is 55 minutes, when it is reprinted.

The following statement will be added to the 2009 NHAMCS forms in place of the assurance statement which has been used to date:

Assurance of Confidentiality – All information which would permit identification of an 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 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).

Also, on page 3, the Introduction Statements under Section I, B1 and B2 - Telephone Screener will be revised to include the following section which also appears in the Introductory Letter (Attachment S). This new section will follow the first paragraph and will read:

Any identifiable information will be held confidential and will be used only by NCHS staff, contractors or agents, only when necessary and with strict controls, and will not be disclosed to anyone else without the consent of your facility. By law, every employee as well as every 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.