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The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

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This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

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Required format:

/^((0?[1-9])|([1-8][0-9])|(9[0-8]))[0-9]{3}$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4}))$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4}))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31))))$/

/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^(?!\.)((?!.*\.{2})[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)(\.[a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF!#$%&'*+\-/=?^_`{|}~\d]+)*@(?!\.)([a-zA-Z0-9\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF\-\.\d]+)((\.([a-zA-Z\u0080-\u02AF\u0300-\u07FF\u0900-\u18AF\u1900-\u1A1F\u1B00-\u1B7F\u1D00-\u1FFF\u20D0-\u214F\u2C00-\u2DDF\u2F00-\u2FDF\u2FF0-\u2FFF\u3040-\u319F\u31C0-\uA4CF\uA700-\uA71F\uA800-\uA82F\uA840-\uA87F\uAC00-\uD7AF\uF900-\uFAFF]){2,63})+)$/i

/^[-+]?\b\d+\b$/

/^[a-z]+$/i

/^\d{10}$/

/^[a-z0-9-_]+$/i

/^[-+]?[0-9]*\.?[0-9]+([eE][-+]?[0-9]+)?$/

/^-?\d+,\d$/

/^-?\d+\.\d$/

/^-?\d+,\d{2}$/

/^-?\d+\.\d{2}$/

/^-?\d+,\d{3}$/

/^-?\d+\.\d{3}$/

/^-?\d+,\d{4}$/

/^-?\d+\.\d{4}$/

/^[-+]?[0-9]*,?[0-9]+([eE][-+]?[0-9]+)?$/

/^($0[2-8]$|0[2-8])\s*\d{4}\s*\d{4}$/

/^(?:$?([2-9]0[1-9]|[2-9]1[02-9]|[2-9][2-9][0-9]|800|811)$?)\s*(?:[.-]\s*)?([2-9]1[02-9]|[2-9][02-9]1|[2-9][02-9]{2})\s*(?:[.-]\s*)?([0-9]{4})(?:\s*(?:#|x\.?|ext\.?|extension)\s*(\d+))?$/

/^\d{4}$/

/^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1}\s*\d{1}[A-Z]{1}\d{1}$/i

/^(0[1-9]|[1-9]\d)\d{3}$/

/^\d{3}-\d\d-\d{4}$/

/^(\d|[01]\d|(2[0-3]))(:[0-5]\d){2}$/

/^([0-9]|[0-1][0-9]|[2][0-3]):([0-5][0-9])$/

/^[0-5]\d:[0-5]\d$/

/^[0-9]{4,9}$/

/^\d{5}(-\d{4})?$/

USIIS Support Request

Please use this form to submit request for support, request immunization records, make changes, updates, and corrections to your immunization records. If you need help with this form, you may email us at usiissupport@utah.gov. We can only updated COVID vaccines, for all others please contact your healthcare provider.

After you select the SUBMIT button, you will see a confirmation page that your response has been received.

Date

Y-M-D H:M:S

Are you an individual or provider?

Individual/Parent

Healthcare Provider/School

What would you like to do?

* must provide value

Help with Docket

Request Immunization Record

Change name

Change contact information

Correct demographic information (Age, gender, race)

Correct missing or extra COVID-19 vaccinations

Ask a question

What would you like to do?

Patient merge/unmerge

USIIS login/password issues

Data interface issues

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

To access your records through Docket

1. Set up your account.

Download the free Docket app.
Login with email, Apple, or Google

2. Search your records.

Select Immunizations from the main menu.
If prompted to enter your immunization PIN: This means you don't have a phone number or email attached to your record. Please fill out a current phone or email in this request and it will be updated.

3. Achieve Immunity

Receive Immunization Alerts
Vaccine verification
Add family members
Easily refresh to see new vaccinations

For questions about Docket, email support@dockethealth.com.

Twitter and Instagram - @dockethealthapp

See troubleshooting guide below.

Attachment:

Docket-App-Troubleshooting-Guide.pdf

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?

Expand

What is your relationship to the subject of this record?

* must provide value

This is regarding my own record.

I am a parent of a minor or legal guardian requesting help on behalf of another individual.

I am a healthcare provider or school staff

reset

What is your USIIS Provider ID

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

Patient information (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 the primary care provider:

Details and comments about this request:

Expand

Other than COVID vaccinations, USIIS is unable to manually add your records to the database. Immunization records are sent to USIIS from healthcare providers. Your healthcare provider can work with you to determine any vaccinations you may need. If your healthcare provider participates in USIIS they can add any of your childhood vaccinations to the immunization registry and send them to USIIS. Please note that participation in USIIS is not required by healthcare providers. You can also go to a local County Health Department to assist you with adding your vaccination records to USIIS.

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 Documentation

(Immunization record, court documents, etc. where relevant)

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 ID is required for immunization records and changes or updates to 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

Expand

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.