Forms and Documents

Client Benefits Register as an
Authorized Organization
Forms &
Use (HL7)

ImmTrac Forms & Documents

Print single copies below or order in quantity by stock number from ImmTrac brochures and posters may also be ordered from the link above. For assistance with ordering, please call the Immunization Branch at (800) 252-9152. 
Stock # Title
General/Miscellaneous Consent Forms: 
C-7 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.
EF11-13366 ImmTrac Adult Consent Form (rev. 05/2012)
Use this form to register as an adult (aged 18 and older) in ImmTrac.
EF11-12955 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.
F11-12956 ImmTrac Disaster Information Retention Consent Form (rev. 05/2012)
Use this form to retain your disaster-related informationn beyond 5 years.
Request an Immunization Record:
F11-11406 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:
F11-11936 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:
C-8 Withdrawal of Consent and Confirmation Form (rev. 04/2014)
Use this form to withdraw your child or yourself from participation in ImmTrac.

Documents for Providers & Payors:



General Fact Sheets:

Helpful Links:

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Last updated February 9, 2017