Utah School Immunization Record

Instructions on how to complete the Utah School Immunization Record

All schools and early childhood programs must have a Utah School Immunization Record (USIR) for each enrolled student. The USIR must be completed by hand or printed from the Utah Statewide Immunization Information System (USIIS). For detailed information on the required immunizations and minimum intervals between vaccines doses, refer to the Utah Immunization Guidebook at immunize.utah.gov.
Instructions for Participating USIIS Users
The following fields will be automatically filled in on the USIR when printed by a participating USIIS User:
• Student Information: Student Name, Gender, Date of Birth, Name of Parent/Guardian (if entered on the Demographics page) and USIIS ID. The Student ID will only print when printed from a school that is enrolled in USIIS and has the students linked to that specific school.
• Vaccine Information: Dates of vaccines given (1st 2nd, 3rd, 4th, 5th/Last), Status, and Due Date.
Completing the Form: Verify information is correct, print form, and fill in any of the necessary missing information below by hand or type.
• Immunization Record Received For This Student: Mark “A statewide registry”. If you used any other records for verification or missing information also mark “Student’s former school” and/or “Legally responsible individual of the student”.
• Proof of Immunity (history of disease): Fill in the status column with “Immunity” for a claim that a child has immunity against a disease which requires vaccination due to previously contracting the disease. A document that includes each antigen being claimed as immune (e.g., varicella, measles, rubella) and signed by a healthcare provider as proof of immunity must be attached to the USIR.
• Exemption: Fill in the exemption column with the type of exemption (religious, personal, or medical) if the student has an exemption. Attach a copy of the exemption form to the back of the USIR. For a medical exemption, a written notice signed by a licensed healthcare provider must also be attached to the USIR.
• Authorized Signature/Date: Sign and date – this is the signature of the school or health personnel who verified the USIR against the source record(s).
Instructions for Non-Participating USIIS Users or users who do not print USIR from USIIS
• Student Information: Fill in the Student Name, Gender, Date of Birth, and Name of Parent/Guardian.
*NOTE - The USIIS ID and Student ID are not required fields to be completed by facilities that are not enrolled in USIIS or users who do not print USIR from USIIS.
• Vaccine Information: Fill in the dates (month, day, and year in the appropriate column i.e., 1st, 2nd, 3rd, 4th, 5th/Last) for each of the required vaccines the student has received. Ensure these dates have been verified by a licensed healthcare professional, registered nurse, authorized representative of a local health department, and/or pharmacist that is on the immunization record(s) you received for that student.
*NOTE – Status is only required to be completed if the student has a past history of disease such as chickenpox. Due Date is not a required field to be completed by facilities that are not enrolled in USIIS or do not print USIR from USIIS.
• Immunization Record Received For This Student: Mark the source of the record(s) used to complete this document.
• Proof of Immunity (history of disease): Fill in the status column with “Immunity” for a claim that a child has immunity against a disease which requires vaccination due to previously contracting the disease. A document that includes each antigen being claimed as immune (e.g., varicella, measles, rubella) and signed by a healthcare provider as proof of immunity must be attached to the USIR.
• Exemption: Fill in the exemption column with the type of exemption (religious, personal, or medical) if the student has an exemption. Attach a copy of the exemption form to the back of the USIR. For a medical exemption, a written notice signed by a licensed health care provider must also be attached to the USIR.
• Authorized Signature/Date: Sign and date – this is the signature of the school or health personnel who verified the USIR against the source record(s).
For further information, visit the Utah Immunization website at immunize.utah.gov or call 801-538-9450