Immunization Consent Form First Responder

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TEXAS DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION REGISTRY (ImmTrac)
FIRST RESPONDER/FAMILY MEMBER REQUEST FORM
(Please print clearly)
For Clinic/Office Use
Client’s Last Name
Client’s First Name
Client’s Middle Name
/
/
Client’s Gender:
Male
Female
Client’s Date of Birth
Client’s Address
Apartment #
Telephone
City
State
Zip Code
County
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services. The immunization
registry is a secure and confidential service that consolidates and stores your immunization records. State law permits the inclusion of
immunization records for first responders and their immediate family members (over 18 years of age) in the Registry. With your
consent, your immunization information will be included in ImmTrac and health care providers can access your immunization history. A
“first responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An
“immediate family member” is defined as a parent, spouse, child or sibling who resides in the same household as the first responder. For
a family member less then 18 years of age, a parent, legal guardian or managing conservator may grant consent for participation as an
“ImmTrac child” by completing the Immunization Registry (ImmTrac) Consent Form (#C-7).
The Texas Department of State Health Services (DSHS) encourages your voluntary participation in the Texas immunization registry.
Request for Inclusion of First Responder or First Responder Family Member Immunization Information
and Release of Immunization Records to Authorized Entities
I understand that, by requesting inclusion below, I am authorizing release of my immunization information to DSHS and I further
understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac”). Once in ImmTrac, my
immunization information may by law be accessed by a physician or other health care provider legally authorized to administer vaccines,
for treating me as a patient.
I understand that I may withdraw this request to include my immunization information in the ImmTrac Registry and my request to
release information from the Registry, at any time by written communication to the Texas Department of State Health Services, ImmTrac
Group – MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
Please mark the appropriate box
to indicate whether you are a First Responder or an Immediate Family Member.
I am a FIRST RESPONDER
I am an IMMEDIATE FAMILY MEMBER (over 18 years of age) of a first responder
By my signature below, I REQUEST inclusion of my immunization information in the Texas immunization registry.
Client: ________________________________________________________________________
Printed Name
_______________________
_______________________________________________________________________________________
Date
Signature
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and
review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See for
more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)
Questions? (800) 252-9152  (512) 458-7284 
ImmTrac FR/FM Stock No. F11-12955
Texas Department of State Health Services  ImmTrac Group – MC 1946 P.O. Box 149347  Austin, TX 78714-9347
Revised 09/12/08
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that a request has been received.
DO NOT fax to ImmTrac. Retain this form in your client’s record.

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