USIIS Support Request

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Required format:

icBtL2Dmj7mUTqJbBIvk3pYKgPmmqSUZhoXu6KS6uDLHH7rPPDmdNQEExjTk

Please use this form to submit support requests for the Utah Statewide Immunization Information System (USIIS).

After you select the SUBMIT button, you will see a confirmation page that your response has been received. Please allow 5-7 business days for your request to be processed. Multiple requests may cause a delay in our response time. Please submit only one request per issue.

If you are having trouble accessing USIIS, use and bookmark our new URL: usiisapps.utah.gov

Date

Y-M-D H:M:S

Are you an individual or provider?

Individual/Parent

Healthcare Provider/School/Other

reset

What would you like to do?

* must provide value

Help with Docket

Request immunization record

Help with school exemption

Change name

Change contact information

Correct demographic information (Age, gender, race)

Ask a question

reset

What do you want to know?

What is Docket used for?

How do I sign up and/or login?

I can't find my records in the Docket app. What should I do?

How do I refresh my Docket account with new data?

How do I share the PDF of my immunization record using the Docket app?

Something else

What do you want to know?

How do I obtain a school vaccine exemption certificate for my child?

Where do I complete the 'Online Immunization Education Module'?

How do I access a completed exemption certificate?

How do I change the 'parent/guardian' name on the exemption certificate?

Something else

Due to recent funding changes, our support team is understaffed and experiencing longer-than-usual turnaround times.

You can quickly and easily access your personal immunization record through the Docket mobile app. You can also access back-to-school forms, update contact information, add family to a shared account, and more.

Please complete the form below if you need further assistance.

How do I change the 'parent/guardian' name on an exemption certificate?

If you need to change/update a parent's name, or if the student's name is showing on the "parent/guardian name" field on the exemption certificate, please follow the instructions below.

1. Use your UtahID credentials to login to https://id.utah.gov. The exemption form pulls the parent/guardian information directly from the UtahID account.
2. Under the 'Account Info' tab, update the account's name fields.
3. Review the updated exemption form at https://usiisapps.utah.gov/exemptions.

More UtahID information can be found at idhelp.utah.gov.

What would you like to do?

Patient merge/unmerge

USIIS login/password issues

Data interface issues

Patient record request

Other support request (Vaccine Inventory, Forecast, VOMS, etc.)

I would like to change the name on record because...

To request changing the legal name in a USIIS immunization record, one must be of legal age
(18 years or older). To request the legal name change of a minor child (under age 18) one must
be the child’s parent or legal guardian at the time of the request.
For name changes due to adoption or court order, the name must first be registered with the
Utah Department of Health Office of Vital Records and Statistics.

Once the Office of Vital Records and Statistics has updated their records, USIIS may
update its record.
Once modified, a USIIS record will not be accessible by the previous legal name.
It may take up to four weeks for Vital Records to process requests.

Please fill out and upload the form below.

Attachment:LegalNameChangeForm_Feb2017.pdf

What is your question?

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What is your relationship to the subject of this record?

* must provide value

I am requesting my own record.

I am the parent/legal guardian requesting the record of a minor.

I am a healthcare provider or school staff.

reset

Child's first name

Child's last name

Child's birthdate

M-D-Y

Please fill out and attach the provider record release form:

https://immunize.utah.gov/immunizationrecordrelease_providers/

For additional provider/user enrollment forms or immunization record release forms please see our website at https://immunize.utah.gov/usiis/usiis-provider-facilities/

Upload provider immunization request form documentation or email form to usiissupport@utah.gov

Upload file

What is your USIIS Provider ID

What is the patient's USIIS ID (if applicable)

Patient information/Name & DOB (if applicable)

What is your support request

Expand

What is your name?

Phone number

First name*	Middle name	Last name*


Other names

Date of birth

* must provide value

M-D-Y

Gender

Race

Please list other race

Expand

Mother's maiden name

Street address
City
State		Zip code

Name of clinic or provider who administered the vaccine(s), or your primary care provider:

Request details:

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Upload a government-issued photo ID.

We will not be able to make changes or share immunization information without an ID.

(Selfies and other non-official forms of ID are not valid)

Upload other documentation.

(Immunization record, court documents, etc., if applicable)

Applicant name

* must provide value

Email address

* must provide value

Phone number

* must provide value

Don't forget to upload your photo ID.

Government-issued identification is required to release your immunization report and to change/update your record.

You will be able to submit this form once a photo ID has been uploaded.

USIIS ID (optional)

Assigned to:

Status

Resolved date

* must provide value

M-D-Y

USIIS comments

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