ImmTrac Forms and Documents
|General/Miscellaneous Consent Forms:|
|ImmTrac - Immunization Registry Consent Form (rev. 05/2012)|
Use this form to register your child, aged 17 and younger, in ImmTrac.
Birth registrars: DO NOT use this form. See F11-11936 below.
|ImmTrac Adult Consent Form (rev. 05/2012)|
Use this form to register as an adult (aged 18 and older) in ImmTrac.
|ImmTrac First Responder/First Responder Family Member Consent Form (rev. 05/2012)|
Use this form to register as a first responder and first responder family members, aged 18 and older.
|ImmTrac Disaster Information Retention Consent Form (rev. 05/2012)|
Use this form to retain your disaster-related information beyond 5 years.
|Request an Immunization Record:|
|Authorization to Release ImmTrac History Form (rev. 04/2012)|
Use this form to authorize release of your or your child's ImmTrac records.
|Newborn Consent Form:|
|ImmTrac Newborn Registration Form (rev. 04/2014)|
Use this form to grant or deny newborn registration in ImmTrac.
For use by birth registrars only.
|ImmTrac Withdrawal Form:|
|Withdrawal of Consent and Confirmation Form (rev. 04/2014)|
Use this form to withdraw your child or yourself from participation in ImmTrac.
|Forms for Providers & Payors:|
|Documents for Providers & Payors:|
|General Fact Sheets:|