Texas Immunization Registry Form

Texas Department of State Health Services

TEXAS IMMUNIZATION REGISTRY (ImmTrac2)

Disaster Information Retention Consent Form

*A parent, legal guardian or managing conservator must sign this form if the client is younger than 18 years of age.
Name

First NameMiddle NameLast Name
Date of Birth (mm/dd/yyyy)

MonthDayYear
Date
Gender

MaleFemale
Telephone
Email address
example@example.com
Address
Apartment # / Building #
City
State
Zip Code
County
Mother's First Name
Mother's Maiden Name
Race (select all that apply)

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther RaceRecipient Refused
Ethnicity (select only one):

Hispanic or LatinoNot Hispanic or LatinoRecipient Refused
The Texas Immunization Registry (ImmTrac2) has been designated as the disaster-related reporting and tracking system for immunizations, antivirals, and other medications administered to individuals in preparation for, or in response to, a disaster or public health emergency. From the time the event is declared over, ImmTrac2 will retain disaster-related information received from health-care providers for a period of 5 years. At the end of the 5 year retention period, client-specific disaster-related information will be removed from the Registry unless consent is granted to retain the client information in ImmTrac2 beyond the 5 year retention period.
The Texas Department of State Health Services (DSHS) encourages your
voluntary participation in the Texas Immunization Registry.

Consent for Retention of Disaster-Related Information and Release of Information to Authorized Entities

I understand that, by granting the consent below, I am authorizing retention of my (or my child’s) disaster-related information by DSHS beyond the 5 year retention period. I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac2”). Once in ImmTrac2, my (or my child’s) disaster-related information may by law be accessed by:
• a state agency, for the purpose of aiding and coordinating communicable disease prevention and control efforts, and / or
• a physician or other health- care provider legally authorized to administer immunizations, antivirals, and other medications, for treating the client as a patient;
I understand that I may withdraw this consent to retain information in the ImmTrac2 Registry beyond the 5 year retention period and my consent to release information from the Registry, at any time by written communication to the Texas Department of State Health Services, ImmTrac2 Group – MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent to retain my disaster-related information (or my child’s information if younger than age 18) in the Texas immunization registry beyond the 5 year retention period.
Client (or parent, legal guardian, or managing conservator:)
Printed Name
Date

MonthDayYear
Date
Signature

Clear
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 http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

Upon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800)252-9152 or (512) 776-7284 Fax: (866) 624-0180 www.ImmTrac.com, Texas Department of State Health Services, ImmTrac2 Group - MC 1946 P. O. Box 149347, Austin, TX 78714-9347
PROVIDERS REGISTERED WITH ImmTrac2

Please enter client information in ImmTrac2 and affirm that consent has been granted. DO NOT fax to ImmTrac2. Retain this form in your client's record.
Should be Empty: