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    Immunization Branch
    Central Office
    1100 West 49th Street
    Austin, Texas 78756

    Phone: (512) 776-3711
    Fax: (512) 458-7288

    TVFC Provider Enrollment Fax: (512) 776-7743

    ASN Provider Enrollment

ImmTrac Forms

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ImmTrac Forms

Use the ImmTrac forms on this page to:

  • register your child in ImmTrac
  • register yourself 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:

Stock #

ImmTrac - Immunization Registry Consent Form PDF document
(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.


PDF document

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

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

ImmTrac Disaster Information Retention Consent Form PDF document
(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 PDF document
(Rev 4/12, english, 1 page PDF)
Use this form to authorize release of your child's ImmTrac records.

Newborn Consent Form:

ImmTrac Newborn Registration Form PDF document
(Rev. 7/22/08, bilingual, 2 page PDF) 
Use this form to grant or deny newborn registration in ImmTrac. 
For use by Birth Registrars only.

ImmTrac Withdrawal Forms:

Withdrawal of Consent and Confirmation Form PDF document
(Rev. 02/2011, bilingual, 2 page PDF)
Use this form to withdraw yourself or your child from participation in ImmTrac.

Last updated October 21, 2013