Provider Forms

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. Census Bureau
Washington, DC 20233-0001

OFFICE OF THE DIRECTOR

Dear

Recently, the U.S. Census Bureau, in partnership with the Centers for Disease Control and
Prevention, sent you a questionnaire(s) to complete for a survey we are conducting. If you
have mailed back the questionnaire(s), thank you. If you received the questionnaire(s), but
have not yet had time to complete the information and return it, please do so as soon as
possible. Your response is important for the success of this survey.
If you have questions, need help filling out the questionnaire or did not receive it, please call
our toll-free number 1–800–595–1339.
Sincerely,

Thomas L. Mesenbourg
Acting Director
U.S. Census Bureau

Anne Schuchat, M.D.
Rear Admiral, United States Public Health Service
Director, National Center for Immunization and
Respiratory Disease

7317-IMMP (4-15-2009)

U.S. DEPARTMENT OF COMMERCE
Economics and Statistics Administration
U.S. Census Bureau
1201 East 10th Street
Jefferson, IN 47132-0001
OFFICIAL BUSINESS
Penalty for Private Use, $300
7317-IMMP (4-2009)

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