Fillable Request for Immunization Records North Dakota Immunization Information (State of North Dakota)

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Request for Immunization Records North Dakota Immunization Information (State of North Dakota)

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Request for Immunization Records
North Dakota Immunization Information System
The North Dakota Immunization Information System (NDIIS) is a confidential, electronic system
that collects immunization data for all North Dakotans. The NDIIS is an important tool to
increase and sustain high vaccination coverage by consolidating vaccination records of children
from multiple providers, generating reminder and recall vaccination notices for each child, and
providing official vaccination forms and vaccination coverage assessments. Children are entered
into the NDIIS at birth through a linkage with electronic birth records. An NDIIS immunization
record can also be initiated by a healthcare provider at the time of the child's first
immunization. The NDIIS has the capability of collecting vaccination data on adult patients as
well as children; however, the NDIIS was created in 1996, so most adults will not have childhood
immunizations in the NDIIS. Most North Dakota children and adults will have at least a partial
immunization record in the NDIIS.
Immunization records from the NDIIS may also be requested by contacting your local public
health unit or healthcare provider.
Please complete this form by clearly printing all information and attaching any additional
supporting documentation required.
• All requests MUST be accompanied with a photocopy of the requestor’s current state-
issued driver’s license or picture I.D. or it will not be processed. Submitted photocopy
MUST be clear enough to see the picture and clearly read the name and birthdate on
the I.D.
• If the record requested is for a person younger than 18, please state your relationship
to the child.
• If the record requested is for a person 18 and older, only the person named on the
immunization record may make the request.
• If the requestor is a social services agency, please provide a signed release of
information form and a copy of the court order granting guardianship to social
services.
Immunization record requests and supporting documentation may either be mailed or emailed
1
to the North Dakota Department of Health. Record requests will not be accepted over the
telephone.
Record requests submitted without the required supporting documentation or with
illegible supporting documentation will not be processed.
Please mail or email your immunization record request form and all supporting
documentation to:
North Dakota Department of Health Email Address: immrecord@nd.gov
Immunization Program
600 E Boulevard Ave, Dept. 301
Bismarck, ND 58505-0200
Please allow up to 5 business days for processing your record request.
1
Immunization record requests and supporting documentation submitted to the North Dakota Department of
Health via email will be kept secure once received and when sent. However, email may not be secure while the
information is in transit from the submitter’s email account to the Department of Health.
NORTH DAKOTA IMMUNIZATION RECORD REQUEST
NORTH DAKOTA DEPARTMENT OF HEALTH
DIVISION OF DISEASE CONTROL
SFN 58454 (08-2019)
Immunization Record Request
Requested Method for Record to be Sent: Mail Email
Requested Immunization Record Information
First Name:
Middle Name:
Maiden Name:
Last Name:
Date of Birth:
Gender: Male Female
Requestor’s Information
Requestor’s Last Name:
Requestor’s First Name:
Relationship: Self Parent
Guardian (provide release of information form)
Street Address:
City:
State:
Telephone Number:
Email Address (if requested to be sent via email):
Supporting Documentation: Driver’s License Release of Information
Court Order Granting Guardianship
By checking this box and typing my name below, I am signing this document
electronically. I agree that my electronic signature is the legal equivalent of my
manual/handwritten signature. I agree that the electronic signature appearing on this
document has the same validity and enforceability as a handwritten signature.
Signature:
North Dakota Department of Health (For Office Use Only)
Date Received:
Date Fulfilled:
Initials:
Record Sent Record Not Found
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Request for Immunization Records North Dakota Immunization Information (State of North Dakota)

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Completed 9 March 2022

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