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)

REGISTRANT WITHDRAWAL FROM NJIIS

Please attach documents to identify the person requesting this withdrawal from 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.

REGISTRANT Information	Parent/guardian information

(iF REGISTRANT UNDER 18 YEARS OF AGE)
Name of Registrant (Print)

Name (Print)

Date of Birth

Address

Medical Record Number

City, State, Zip Code

Name of Primary Health Care Provider

Relationship to Registrant

I have received information about the New Jersey Immunization Information System (NJIIS) and understand that the purpose of this program is to remind health care providers when immunizations are due and to serve as a repository for a person’s immunization history.

I wish to disenroll my child/myself as a registrant in the New Jersey Immunization Information System (NJIIS) at this time.

I have been provided with information on how to reactivate my child/myself in the NJIIS should I decide to participate in the future.
Signature of Registrant (or Parent/Guardian, if Registrant under 18 years of age)	Date
Signature of Witness	Date
Mail completed form with copies of official supporting documents to the above address. The Vaccine Preventable Disease Program will retain a copy of the Registrant Withdrawal form on file.

IMM-47

JUL 12

IMM-47, Registrant Withdrawal from NJIIS

IMM-47, registrant withdrawal, NJIIS, IMM, VPDP, vaccine preventable disease program, withdrawal,

Elaine White

2007-10-15

ewhite

NJDOH