Michigan Care Improvement Registry (MCIR)
School/Childcare Petition to Modify MCIR Data
See page 2 for the Petition form.
All boxes in both the “Requestor’s Information” and the “Child’s Information” sections MUST be completed. Failure to do
so will automatically void the request.
Legal Name Change (Adoption):
Only the parent/legal guardian may request a legal name change. They can do so using this form:
To modify date of birth or eradicate errors in a name:
1) Verify the correct date of birth and/or child name with the documentation presented to your school/childcare by a
2) Print or type the corrected information on the Petition form in the box(es) provided.
3) Fax or mail only the Petition. Do not send documentation of changes.
If you find that the child has more than one MCIR record in the system, submit the information as follows:
1) Complete the “Child’s Information” section as required except the MCIR ID number.
2) In the MCIR ID number box, write the word “Duplicates.”
3) In the “Vaccine Name” boxes, list each MCIR ID number associated to the child.
4) If the child’s legal name has changed, be sure to include that information in the area provided on the Petition. All
of the records will then be changed to reflect the correct name before being marked for merging.
The records will automatically be merged under the MCIR ID number that was populated by the state Vital Records office
(birth certificate) if available. If the vital records info is not available, the records will be merged under the MCIR ID number
that has the latest health care provider shot entry
To Change Immunization (Shot) Dates:
Schools and Childcares have the ability to delete or modify any shots entered by their facility. If the shot date is red
and underlined, click it for modification.
Any “white data” shots cannot be modified by schools/childcares. This data is entered by a healthcare professional.
Have the parent/guardian contact the child’s physician or local health department to fix any errors.
If the data is highlighted in red but not underlined, a Petition to Modify MCIR Data form is required along with a copy
of the immunization record provided by the parent/guardian. On the Petition, please provide:
1) Vaccine name (e.g., DTP, Polio, etc.)
2) MCIR shot date
3) Documentation’s shot date, a Doctor’s record, NOT a MCIR printout
4) Check either “Modify” or “Delete”
5) NOTE: Putting the phrase “See Attached” is not acceptable. Each shot modification MUST BE spelled out on
6) EXCEPTION: If you find duplicate shot data under the same vaccine, highlighted in red or not, you may
request that the duplicate dates be deleted. Simply put “Duplicate Dates” in the “vaccine name” box. You do
not have to submit a copy of the parent/guardian’s documentation to make this particular request.
Attach additional sheets if needed. Documentation is required to make any changes to MCIR shot dates.
All Petitions should be Faxed OR Mailed to: Division of Immunization, Michigan Department of Health and Human Services
PO Box 30195
Lansing MI 48909
If you have any questions regarding this form, please call 517-335-8159 and ask for the MCIR Program.