IMMUNIZATION REGISTRY DATA EXCLUSION REQUEST
State Form 52308 (R3 / 1-11)
Indiana State Department of Health, Immunization Division
INSTRUCTIONS: 1. Complete and sign this form.
2.Follow submission instructions in Section B.
A.Individual to Exclude
All fields required to identify if the individual has data in the immunization registry, and to prevent new data from being entered.
Name ______________________________________________________ Date of Birth (month/day/year) _______________
Street Address (number and street) ___________________________________________________________________________
City ___________________________________ ZIP Code ___________ Mother’s Maiden Name _____________________
B.Type of Exclusion
Check all requested exclusion types. If requesting both, complete submission instructions for both exclusion types.
Medical provider is not to enter individual’s data into registry
Complete form and submit to medical provider. Form will be kept with individual’s medical record at provider facility.
Exclusion request applies only at medical provider facility receiving this document.
Immunization Registry is to permanently exclude (opt-out) individual
Complete form and submit to the ISDH Immunization Registry. Fax to 317/233-8827 or mail to Indiana State Department of Health, Immunization Division, Attn: Registry Exclusion, 2 N Meridian, 6A, Indianapolis, IN 46204.
Exclusion request will be processed within 5-7 business days of receipt. Confirmation request complete sent via email.
C.About the Immunization Registry
The Indiana Immunization Registry, known as CHIRP (Children & Hoosiers Immunization Registry Program), is a web-based application operated by the Indiana State Department of Health (ISDH) Immunization Division. CHIRP is developed under the authority of Indiana Code §16-38-5. Immunization data is confidential and only available to authorized registry users.
Immunization data, known as immunization records, may be included in the registry without individual, parent or guardian consent. An individual, parent or guardian may request to exclude their immunization data from the registry at any time under the authority of Indiana Code §16-38-5.
D.Exclusion Terms & Conditions
Please exclude any and all data related the individual listed above from the Children & Hoosiers Immunization Registry Program (CHIRP). By requesting that this data be excluded from the immunization registry, I understand and agree to the following:
The exclusion of data from the immunization registry is permanent. The exclusion, or opt-out process, cannot be reversed.
Immunization data for the individual listed above will no longer be available in the registry. The individuals name and birth date, however, will be stored in a table designed to prevent any new data related to the individual from being entered into the database. The information in this table is not accessible through the registry application.
The individual, parent or guardian is responsible for maintaining a hard copy of immunization records as proof of immunity.
Failure to maintain hard copy immunization records may result in the individual requiring re-vaccination to be in compliance with immunization requirements.
E.Acknowledge & Sign
Signature of Individual, Parent or Guardian ______________________________________ |
Date (month/day/year) ___________ |
Printed Name _________________________________________________ |
Relationship |
_____________________________ |
Email Address ________________________________________________ |
Telephone Number ________________________ |
For Office Use Only |
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Date Request Received (month/day/year) ____________________________________ |
Record SIIS Number |
______________________ |
Request Processed by _________________________________________________ |
Date (month/day/year) |
_______________________ |
Confirmation Notice Sent by _____________________________________________ |
Date (month/day/year) |
_______________________ |
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