The purpose of this form is to enroll healthcare providers, pharmacies, schools, and other eligible organizations in the Utah Statewide Immunization Information System (USIIS) and to request access for authorized staff.

After you submit your request, 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.

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

PRIVACY NOTICE

Utah DHHS requires the information below to determine if you are authorized to access the USIIS web application. The information provided will only be used by DHHS and, if necessary, by contractors who are part of the technical team that manages the service. Without this information, we will not be able to determine if the requesting individual or organization are eligible, and we will not be able to grant access to USIIS. We do not sell your personal information. This data is part of the record series 29786, which provides more information on how the data are used and the retention schedule.

What do you want to do?

Enroll a healthcare facility, school, or other eligible organization in USIIS

Request a user account/access through an organization already enrolled in USIIS

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Have you accessed USIIS in the past, either through your current workplace or a prior organization?

Yes

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Which type of organization are you requesting access through?

Healthcare provider

School/early childhood care provider

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Is your organization an Intermountain Health facility?

Yes

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Organization name*:		USIIS provider ID:
If you need to look up your facility's USIIS ID, click HERE.
Street address*:
City*:	State*:		Zip code*:
Telephone*:	Ext:		Fax:

Do you need access to more than one clinic?

Yes

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Which additional clinic(s) do you need access to?

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Do you need to end your access at any clinic(s)

Yes

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Which clinic(s) do you need to end access with?

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First name*:		Middle name:
Note: Each user needs their own USIIS account. Sharing accounts is prohibited.
Last name*:		Maiden/other last names used:
Birthdate*:		Are you a vaccinator?*
Title/role at facility*:		Office phone*:

! Email*:		A Utahid account is required to access USIIS!
! The USIIS portal uses Utahid for multi-factor authentication. If you have an existing Utahid account, you'll need to ensure that your USIIS account is created using the email that your Utahid account is under. If you do not have a Utahid account, create one HERE, then complete this form. For help and FAQs, visit idhelp.utah.gov.

Supervisor's name*:		Supervisor's email*:

Supervisor's phone:

* must provide value

Indicate which USIIS services are required for your job at ______. These are services that cannot be accessed from within the Cerner iCentra application.

Clinic Reports and Batch Processes

Doses Administered Reporting

Vaccine Inventory

USIIS NOTICE

The Utah Statewide Immunization Information System (USIIS) is a confidential computerized immunization information system operated and maintained by the Utah State Department of Health and Human Services (DHHS). USIIS access is available only to authorized users.

USIIS is developed under the authority of the following provisions of the Utah Code: Title 26, Chapter 3, Health Statistics: Title 53A, Chapter 11, Part 3, Immunization of Students; and Utah Administrative Rule R386-800 Immunization Coordination.

As required by Section 63-46a-3(5), any person who violates any provision of the rule may be assessed a civil money penalty as provided in Section 26-23-6.

To participate in and receive access to USIIS, I agree to the following conditions:

		1. I will use USIIS only for the submission and access of patient or vaccination information.
		2. I will access USIIS only when needed to assure adequate immunization of a patient, to avoid unnecessary immunizations, to confirm compliance with immunization recommendations, and to control disease outbreaks.
		3. I have read and will adhere to the requirements of the USIIS Confidentiality and Security Policy.
		4. I will safeguard my username and password against use by another individual.
		5. I will access USIIS only as an employee of the above named facility.
		6. I will not make copies of individuals' records except as authorized in the USIIS Confidentiality and Security Policy.
		7. I will only discuss information in a USIIS record as necessary for medical care of a patient and never in a manner or location that would reveal the patient's identity to unauthorized individuals.
		8. DHHS may terminate current and future access to USIIS at any time for failure to comply with these conditions.

To participate in and receive access to USIIS, I agree to the following conditions:

		1. I will use USIIS only for receipt and input of student and/or vaccination information and in accordance with the Family Educational Rights and Privacy Act (FERPA) where applicable.
		2. I will access USIIS only for the healthcare needs of students or to meet reporting requirements.
		3. I will access USIIS only when needed to assure adequate immunization of a student, to avoid unnecessary immunizations, to confirm compliance with immunization requirements, and to control disease outbreaks.
		4. I have read and will adhere to the requirements of the USIIS Confidentiality and Security Policy.
		5. I will safeguard my user name and password against use by another individual.
		6. I will access USIIS only as an employee of the above named school/facility.
		7. I will not make copies of individuals' records except as authorized in the USIIS Confidentiality and Security Policy.
		8. I will provide USIIS with demographic and immunization information about students receiving vaccinations in the facility. I will submit all immunization information (historical non-administered and/or administered) to USIIS promptly after obtaining it and in accordance with the Family Educational Rights and Privacy Act (FERPA) where applicable.
		9. I will allow parents/guardians to inspect, copy, and if necessary, amend or correct their child's immunization record if he/she demonstrates that record is incorrect. The corrected information shall be entered into USIIS or a local system and sent to USIIS via a data interface, and in accordance with the Family Educational Rights and Privacy Act (FERPA) where applicable.
		10. I will cooperate with the DHHS in notifying individuals or parents/guardians about the USIIS system and provide information about their right to withdraw from the system. Information will be available to individuals and parents/guardians who wish to withdraw. DHHS is responsible for withdrawing the child or individual from USIIS.
		11. I will not sub-license, distribute, sell, supply, modify, adapt, amend, incorporate, merge or otherwise alter the USIIS web-based system. I will not attempt to decompile, reverse engineer, otherwise disassemble or attempt to derive any source code relating to the USIIS service.
		12. I will only discuss information in a USIIS record as necessary to confirm compliance with immunization requirements and never in a manner or location that would reveal the student's identity to unauthorized individuals.
		13. DHHS may terminate current and future access to USIIS at any time for failure to comply with these conditions.

Organization name:		USIIS provider ID:
If you need to look up your facility's USIIS ID, click HERE.
Street address:
City:	State:		Zip code:
Telephone:	Ext:		Fax:

Primary contact first name*:	Primary contact last name*:
Email address*:	Provider type*:

Will this facility be enrolling in the Vaccines for Children (VFC) Program?*	Will your organization use an EHR interface?*

Which EHR interface?

* must provide value

Do you want an email with information on how to establish an EHR interface connection?

Yes

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I. Introduction: What is USIIS?

The Utah Statewide Immunization Information System (USIIS) is a confidential, population‐based computerized system that records immunization doses administered by participating facilities to persons residing in Utah. USIIS is a life‐span system, designed to coordinate immunization services for persons of all ages. USIIS is operated by the Utah Department of Health and Human Services (DHHS).

At the point of clinical care, USIIS provides consolidated immunization histories for use by a vaccination provider in determining appropriate client vaccinations. At the population level, USIIS provides aggregate data on vaccinations for use in guiding public health action with the goals of improving vaccination rates and reducing vaccine‐preventable disease.

USIIS provides for the sharing of immunization information among authorized users. Participation in USIIS by healthcare providers is voluntary. USIIS is an "opt‐out" system, requiring individuals who do not want their or their child's immunizations in USIIS to request to opt out of the system.

USIIS is designed and operated to protect the security of data, privacy of participants, and confidentiality of information.

USIIS is developed under the authority of the following provisions of the Utah Code: Title 26, Chapter 3, Health Statistics; Title 26, Chapter 6, Communicable Diseases Control Act, Section 26‐1‐17.5; Title 53A, Chapter 11, Part 3, Immunization of Students, and the Utah Administrative Rule (R386‐800) Immunization Coordination.

II. Consent

Utah Administrative Rule (R386‐800) Immunization Coordination became effective June 28, 2000. This rule established a requirement allowing individuals to withdraw (i.e., opt out) from the USIIS registry.

A. Voluntary Participation

Individual participation in the immunization registry is voluntary. Immunization records may be included in the system unless the individual or parent/guardian withdraws.

An individual will be included in the system until such time as the individual withdraws from the system.

Utah Code Section 26‐3‐7(6) permits that under specific circumstances individually identifiable immunization information may be released to "health care personnel or public health personnel who has a legitimate need to have access to the information in order to assist the patient or to protect the health of others closely associated with the patient."

B. Notification

The DHHS will provide information on the use of USIIS directly to parents/guardians at birth hospitals and birthing centers. The DHHS will also provide USIIS participation notification materials to participating facilities for them to display.

Participating facilities shall cooperate with the DHHS in providing information about USIIS to individuals or parents/guardians and their right to withdraw from the system.

C. FERPA (for public schools only)

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education.

FERPA gives parents/guardians certain rights with respect to their children's education records. Generally, schools must have written permission from the parent or guardian before releasing any information, other than "directory" information (i.e. student's name, address, phone number) from a student's education record to any organization or agency that does not have a legitimate educational interest.

In Utah, immunization records are part of a student's education record, and therefore, permission must be obtained from the parent/guardian prior to sharing or including the immunization record in USIIS. The school's annual FERPA notification process may be used to obtain parent / guardian permission. The DHHS will provide schools with the appropriate format and language to assist in this process.

D. Withdrawal

An individual or parent/guardian may withdraw their participation from the system at any time. Individuals or parents/guardians may obtain a withdrawal form by contacting the DHHS or by visiting the USIIS website.

Utah Department of Health and Human Services
USIIS Program
P.O. Box 142012
Salt Lake City, Utah 84114‐2012
Phone: (801) 538‐9450 or (800) 678‐3440
Fax: (801) 538‐9440

https://immunize.utah.gov/usiis/

A withdrawal form with the individual, parent, or guardian's signature must be received in order to complete the withdrawal request.

E. Re‐enrollment

If an individual or parent/guardian has withdrawn consent from USIIS but would like to re‐enroll, they may do so by contacting the USIIS Program at the above contact information.

III. Use of Data and Classification of Users

USIIS may be accessed only by authorized users at participating facilities, including healthcare personnel, schools, day care centers, publicly funded programs, pharmacies and DHHS. Authorized users may access USIIS only when needed to coordinate immunization services of clients-such as assuring adequate immunizations, avoiding unnecessary immunizations, confirming compliance with mandatory immunization requirements, and/or controlling disease outbreaks

Health plans, policy makers, and bona fide researchers may request access to the USIIS information for a specified period, solely for valid research and statistical purpose determined in accordance with Utah Code 26‐3‐ (3).

Individuals or parents/guardians may query their own or their child's immunization information contained in USIIS through their healthcare provider if the provider participates in USIIS, through a participating school or day care, or by submitting a Release of Immunization Record form to the DHHS. Individuals or parents/guardians may obtain the form by contacting the DHHS or by visiting the USIIS website. Authorized provider, school, and day care personnel shall allow the individual or parent/guardian to inspect, copy, and if necessary, amend or correct their
immunization records.

IV. Data Access and Security Procedures

A. Participating Facility Enrollment

Facilities are required to complete and sign an Enrollment Agreement form and abide by its requirements. The enrolled facility is responsible for the actions of their users regarding the confidentiality and security of information contained in USIIS. Participating facilities agree to usage and privacy and security conditions described in the Enrollment Agreement.

A facility shall require each staff user to read this policy and sign the User Confidentiality and Security Agreement. Once completed, they may access identifiable patient information in the system only for authorized purposes.

B. User Confidentiality and Security Agreement

Individual users must be affiliated with a participating facility.

A facility shall require each staff member who becomes an authorized USIIS user to read this policy and sign the User Confidentiality and Security Agreement. Once completed, they may access identifiable patient information in the system for authorized purposes.

All USIIS users shall safeguard their username and password, and must:

1. NOT give a username and password to others
2. NOT post a username and password that is visible to others

C. Penalty

Any person who violates any provision of the User Confidentiality and Security Agreement or this USIIS Confidentiality and Security Policy may be assessed a civil money penalty not to exceed the sum of $5,000 or be punished for violation of a class B misdemeanor for the first violation and for any subsequent similar violation within two years for violation of a class A misdemeanor (Utah Administrative Rule R386‐800‐8).

D. USIIS Program Agreement

The DHHS shall maintain reasonable and appropriate administrative, technical, and physical safeguards to ensure the integrity and confidentiality of health information as stated in this policy. This includes:

1. The USIIS database resides in a secured area with physical and software preventative
  measures to protect the underlying network infrastructure from unauthorized access,
  misuse, or improper disclosure.
2. The USIIS uses encryption technology for data at rest and in transport.
3. The DHHS requires annual confidentiality and data security training for its staff.

V. References
CDC (Gail Horlick). 1997, 1999, 2000. Community Immunization Registries Manual: Chapter II Confidentiality. Prepared by All Kids Count Program of the Task Force for Child Survival and Development, The National Immunization Program of the Centers for Disease Control and Prevention, The national Vaccine Advisory Committee. CDC. Immunization Information System Functional Standards, 2013‐2017. http://www.cdc.gov/vaccines/programs/iis/func‐stds.html

To participate in and receive access to USIIS, I agree to the following conditions:

		1. I will use USIIS only for the submission and access of patient or vaccination information.
		2. I will access USIIS only when needed to assure adequate immunization of a patient, to avoid unnecessary immunizations, to confirm compliance with immunization recommendations, and to control disease outbreaks.
		3. I understand the USIIS service and related data is the property of the Utah Department of Health and Human Services (DHHS). The Utah DHHS retains all rights in USIIS and grants the Provider a non-exclusive license to use the service.
		4. I have read and will adhere to the requirements of the USIIS Confidentiality and Security Policy.
		5. I will ensure staff safeguard their issued USIIS usernames and passwords against use other than allowed by the USIIS User Confidentiality and Security Agreement. I understand that I am responsible for the actions of staff regarding the confidentiality of information contained in the system. Any use, unauthorized disclosure, or dissemination of confidential information is in violation of the Confidentiality and Security Policy and may result in significant criminal or civil penalties.
		6. I will immediately notify the Utah USIIS Program of any unauthorized use or disclosure of, or any unauthorized access, or any theft or loss of data I suspect or that comes to my attention.
		7. I will notify the Utah USIIS Program when a user terminates employment so that the user's access can be removed, thereby maintaining the confidentiality and security of the system.
		8. I will provide USIIS with demographic and immunization information about patients receiving vaccinations in the facility. I will submit all immunization information (historical non-administered and/or administered) to USIIS promptly after obtaining it.
		9. I will allow parents/guardians to inspect, copy, and if necessary, amend or correct their child's immunization record if he/she demonstrates that record is incorrect. The corrected information shall be entered into USIIS or a local system and sent to USIIS via a data interface.
		10. I will cooperate with the DHHS in notifying individuals or parents/guardians about the USIIS system and provide information about their right to withdraw from the system. Information will be available to individuals and parents/guardians who wish to withdraw. DHHS is responsible for withdrawing the child or individual from USIIS.
		11. I will not sub-license, distribute, sell, supply, modify, adapt, amend, incorporate, merge or otherwise alter the USIIS web-based system. I will not attempt to decompile, reverse engineer, otherwise disassemble or attempt to derive any source code relating to the USIIS service.

You must agree to all of the conditions above to proceed

Name (print/type)*:
Signature*:
Submission date*:

Assigned to:

Status:

Resolved date:

* must provide value

M-D-Y

USIIS comments:

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