Forms and Documents

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Find the Document You're Looking for:

Forms for the General Public

• Consent Forms for the Public – Minors and Adults
  
• Immunization Record Request
• Withdrawal Form

First Responders

• Consent Form for First Responders and Family Members
  
• Disaster Information Retention Form

Providers and Organizations

• Newborn Registration Form
  
• Manuals for Providers and Organizations

Print or order in quantity at www.ImmunizeTexasOrderForm.com. For assistance, call the Immunization Unit at (800) 252-9152. 

ImmTrac2 Forms & Documents

Stock #	Title
Consent Forms for Minors and Adults:
C-7	Immunization Registry (ImmTrac2) - Minor Consent Form (rev. 09/2017)  Use this form to register your child, aged 17 and younger, in ImmTrac2. Birth registrars: DO NOT use this form. See F11-11936 below.
C-7A	Registro de Inmunización (ImmTrac2) - Formulario de Consentimiento Para Menores (rev. 03/2017)
EF11-13366	Immunization Registry (ImmTrac2) - Adult Consent Form - (rev. 09/2017) Use this form to register as an adult (aged 18 and older) in ImmTrac2.
EF11-1366A	Registro de Vacunas (ImmTrac2) - Formulario de Consentimiento Para Adultos (rev. 03/2017)
Request and Immunization Record:
F11-11406	Immunization Registry (ImmTrac2) Authorization to Release Official Immunization History (rev. 03/2017) Use this form to authorize the release of your or your child's ImmTrac2 records.
ImmTrac2 Withdrawal Forms:
C-8	Immunization Registry (ImmTrac2) - Withdrawal of Consent and Confirmation Form (rev. 03/2017) Use this form to withdraw your child or yourself from participation in ImmTrac2.
C-8A	Registro de Inmunización (ImmTrac2) - Retiro de Consentimiento y Confirmación (rev. 03/2017)

Stock #	Title
F11-12955	Immunization Registry (ImmTrac2) First Responder/First Responder Family Member Consent Form (rev. 03/2017) Use this form to register as a first responder and first responder family members, aged 18 and older.
F11-12955A	Registro de Inmunización (ImmTrac2) - Formulario de Solicitud de Personal de Primera Respuesta / Un Familiar (rev. 03/2017)
F11-12956	Immunization Registry (ImmTrac2) Disaster Information Retention Consent Form (rev. 03/2017) Use this form to retain your disaster-related information beyond 5 years.
F11-12956A	Registro de Inmunización (ImmTrac2) - Formulario de Consentimiento de Retención de Información Sobre el Desastre (rev. 03/2017)

Stock #	Title
Newborn Consent Form:
F11-11936	ImmTrac2 Newborn Registration Form - Bilingual (rev. 03/2017) Use this form to grant or deny newborn registration in ImmTrac2. For use by birth registrars only.
Manuals:
11-14955	ImmTrac2: Texas Immunization Registry User Manual (rev. 03/2017) The ImmTrac2 User Manual provides information on the new system and  how to navigate through the system.
11-14972	ImmTrac2 Implementation Guide for Immunization Messaging: HL7 Version 2.5.1 (rev. 01/2017) The Implementation Guide provides specifications, standards, and examples for creating HL7 2.5.1 messages for data submissions for ImmTrac2.
11-14977	ImmTrac2 Provider Online Enrollment Manual (rev. 02/2017) The Provider Online Enrollment Manual provides information on the ImmTrac2 registration and renewal processes.
Coming Soon:
11-11445	Electronic Transfer Standards for Providers Use this document only if you are a Provider. If you need information for payors, contact ImmTrac2 Customer Support at (800) 252-9152 or e-mail ImmTrac2@dshs.texas.gov.
11-12158	Payor Information
11-12222	ImmTrac2 Consent Guidelines for Providers
E11-11402	Frequently Asked Questions (FAQs) for Healthcare Providers
E11-12934	New User Welcome Kit
E11-14181	ImmTrac2 Consent Withdrawal Process for Providers Who Affirm Consent
E11-14182	Meaningful Use (HL7) Quick Guide