Certification
Form
OMB
No. 0915-0282
Expiration date: 05-31-2004
MEMBERSHIP IN, AND RECEIPT OF THE SMALLPOX
VACCINE UNDER, AN APPROVED SMALLPOX EMERGENCY RESPONSE
PLAN
The
certification is subject to audit by the U.S. Department
of Health and Human Services’ Office of Inspector
General, the U.S. Department of Justice, the U.S.
Department of Labor, and/or the General Accounting
Office.
1.
INFORMATION ABOUT THE INDIVIDUAL WHO RECEIVED THE
SMALLPOX VACCINATION
The
individual is or was a member of, and received the
smallpox vaccine under, a U.S. Department of Health
and Human Services (HHS), State, or local smallpox
emergency response plan (a Plan).
| Name: |
Social
Security Number: |
Address:
Date
of smallpox vaccination administered under a Plan:
Check
the box that best describes the emergency response
role of the individual who was vaccinated:
| [
] health care worker |
[
] firefighter |
[
] emergency medical worker |
| [
] law enforcement officer |
[
] security-related worked |
[
] public safety worker |
| [
] support worker for above persons (please specify) |
2.
CERTIFYING ENTITY INFORMATION
This
section is to be completed by an authorized representative
of an entity that administered the smallpox vaccine
to the individual described above under a Plan.
Name
of Representative:
Name
of entity:
Address:
Telephone
number:
This
entity participated in the administration of the smallpox
vaccine through an HHS-approved smallpox emergency
response plan and is best described as (check one):
| [
] The U.S. Department of Health and Human Services |
[
] State government |
| [
] Local government |
[
] Private health care entity |
Name
of the HHS-approved smallpox emergency response plan
in which the individual described in Section 1 is/was
a participant:
I
have reviewed all of the information entered on this
form for accuracy, and certify that the information
is true, complete, and accurate to the best of my
knowledge. I understand that if I knowingly and willingly
made any misrepresentation or false statement in this
information, I may be subject to prosecution (a fine
and/or imprisonment for up to 5 years) under Section
1001 of the United Stated Criminal Code (18 U.S.C.
§ 1001).
| Signature
of Individual signing on behalf of the entity |
Title |
Date |
PRIVACY
ACT STATEMENT
Section 2 of Public Law 108-20 and the Debt Collection
Improvement Act of 1996 authorize collection of this
information. It will be used to determine requesters’
eligibility to receive payments. This information
will be disclosed to the U.S. Department of Health
and Human Services and its consultants; and Federal,
State, or local law enforcement agencies if the Government
becomes aware of a possible violation of civil or
criminal law. Furnishing the information including
the Social Security Number on this form is voluntary,
but failure to do so may delay or prevent the receipt
of a payment. The information collected will be maintained
confidentially pursuant to the Privacy Act.
Contact:
smallpox@hrsa.gov
or 1-888-496-0338
 |
