Parent/Guardian Record Request
ALERT Immunization Information System (IIS) is a statewide registry that records vaccinations administered in Oregon,
from either public or private providers. ALERT IIS helps parents, health care providers, schools and other authorized
users as defined below to know an individual’s immunization status.
State law
and Oregon Administrative Rules
cover collection and release of information in ALERT IIS. By law,
information is confidential and can only be shared with authorized users, including an individual’s health care provider,
school, childcare facility, insurer, local health department, the individuals themselves or their parent if the person is a
Parents and legal guardians can access records on behalf of their children until the child turns 18; after that point, the
individuals themselves must request a record. If you would like a copy of your child’s immunization record, please
complete the following
Child’s Name - First:__________________________ Middle: ________________ Last:_____________________________
Address:_____________________________________________ City, State, Zip:_________________________________
Child’s Date of Birth: __________________ Place of Birth: ______________________________ Gender: Female Male
I understand that, as a parent or guardian of a child under 18, I may request my child’s immunization record from ALERT
IIS up to four (4) times within one calendar year free of charge. Additional copies of my child’s immunization record may
be provided based on a reasonable fee established by the Director of ALERT IIS.
Please send the record to one of the following authorized users:
Health Care Provider School Childcare Facility Myself (Parent/Guardian)
Recipient/To The Attention Of: ____________________________ Name of Organization: ____________________________
Fax Number: ______________________________ Phone Number: _____________________________________________
Mailing Address:___________________________________________ City, State, Zip:______________________________
By signing this agreeement, I state that I am the parent or guardian for the child listed above.
Name of Parent/Guardian:_________________________________________________ Telephone Number:_______________________
Signature:________________________________________________________________________ Date:_______________________
For Office Use Only
800 NE Oregon Street, Suite 370
Portland, Oregon 97232
Phone: (800)980-9431
Fax: (971)673-0276
Date Received: ________________ Record Found, Date Sent: __________________ Initials: _________
Record Not Sent
ORS 433.090 to ORS 433.102
OAR 333-049-0100 to OAR 333-049-0130 Parent, Guardian Record Request: 6-2010
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