New Jersey Department of Health

Vaccine Preventable Disease Program

P.O. Box 369, Trenton, NJ 08625-0369

609-826-4860

www.njiis.nj.gov

NEW JERSEY IMMUNIZATION INFORMATION SYSTEM (NJIIS)

REQUEST FOR CHANGE TO NJIIS IMMUNIZATION RECORD

Please attach documents to identify the person requesting this change to the NJIIS immunization record. Some examples of acceptable forms of identification are: a state-issued photo driver’s license with address; a state-issued photo non-driver’s identification card with address; a similar form of identification issued by this State, another state, or the Federal government; or a photo identification card issued by a New Jersey county clerk.

Also include immunization and/or medical documentation to support the change requested.

INFORMATION AS IT CURRENTLY APPEARS IN njiis
Name of Registrant (Print)

Date of Birth

Street Address

NJIIS Registry ID Number (if known)

City	State	Zip Code

Name of Parent/Guardian

Telephone Number

Name of Current Primary Health Care Provider

Telephone Number

SECTION A – DEMOGRAPHIC INFORMATION CHANGE(S) *
Name (Print)

Date of Birth

Street Address

City	State	Zip Code

Name of Parent/Guardian

Telephone Number

SECTION B – medical information change(S) *
Lead

Newborn Hearing Screening

TB

Other

SECTION C – immunization information change(S) *
Vaccine Type	Date Dose Administered	Name of Health Care Provider	Other
Name of Requestor (Print)

Relationship to Registrant

Signature of Requestor

Date of Request

* attach a written statement explaining the reason(s) for this change to the NJIIS immunization record

Mail completed form with copies of official supporting documents to the address above.

IMM-45

JUL 12

IMM-45, Request for Change to NJIIS Immunization Record

IMM-45, IMM, request for change to NJIIS immunization record, NJIIS, request for change, immunization, vaccine preventable disease program, VPDP

Elaine White

2007-08-06

ewhite

NJDOH