Free 52308.pdf - Indiana

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: _______________________