Use the ImmTrac forms on this page to:

• register your child in ImmTrac
• register first responders and immediate family members in ImmTrac
• retain your disaster-related information in ImmTrac beyond 5 years
• authorize release of your or your child’s ImmTrac records
• register newborn consent (for use by Birth Registrars)
• withdraw registration from the ImmTrac program

Print single copies below or order in quantity by stock number from our Literature & Forms page.

ImmTrac Consent Forms:

ImmTrac - Immunization Registry Consent Form 
(Rev. 5/18/12, bilingual, 2 page PDF)
Use this form to register your child in ImmTrac.
Birth registrars: DO NOT use this form, see F11-11936 below.

F11-13366

ImmTrac Adult Consent Form
(Rev. 6/30/11, bilingual, 2 page PDF)
Use this form to register adults in ImmTrac.

ImmTrac First Responder Request Form 
(Rev 9/12/08, bilingual, 2 page PDF)
Use this form to register first responders.

ImmTrac Disaster Information Retention Consent Form 
(Rev 9/3/09, bilingual, 2 page PDF)
Use this form to retain your disaster-related information beyond 5 years.

Authorization to Release ImmTrac History Form 
(Rev 4/12, english, 1 page PDF)
Use this form to authorize release of your child's ImmTrac records.

Newborn Consent Form:

ImmTrac Withdrawal Forms: