IMMUNIZATION DATA REMOVAL
State Form 52308 (R2 / 6-09)
INDIANA STATE DEPARTMENT OF HEALTH, IMMUNIZATION PROGRAM
INSTRUCTIONS:
1. 2.
Complete and sign this form and sign in front of a Notary Public. Return the form by fax to 317-233-8827 or by mail to: Immunization Department, 2 North Meridian Street, Section #6A-22, Indianapolis, IN 46204.
Please remove the immunization record for the person indicated below from the Children and Hoosiers Immunization Registry Program (CHIRP). I understand that this patient will be permanently blocked from re-entry into the Registry and that this may not be reversed in the future.
Please remove the following individual from CHIRP (all fields are required): Legal First Name: ____________________________ Date of Birth (month/day/year): ___________________ Legal Last Name: ______________________________ Mother's Maiden Name: _________________________
Address (number and street): ___________________________________________________________________ City/State/ZIP code: _________________________________________________________________________
I understand that the immunization record for the above individual will no longer be available through CHIRP. I understand that I will be required to maintain a hard copy record for the purposes of reporting and verification.
Relationship to above individual:
self
parent
legal guardian
other: _________________
________________________________________________________ Signature of Individual/Parent/Legal Guardian
_____________________________ Date (month/day/year)
Printed Name: _____________________________________________________________________________ Address (number and street): ___________________________________________________________________ City/State/ZIP code: ______________________________________________________________________ E-mail: _____________________________________
Telephone: ________________________________
STATE OF INDIANA
) ) SS: COUNTY OF ___________ ) Subscribed and sworn to before me, a Notary Public in and for said County and State, this _______day of _________________________, 20___.
[Seal]
________________________________________ Notary Public
My Commission Expires (month/day/year): ______________ County of Residence: _______________________