Immunization Updates

Information Needed to Access Connecticut Immunization Records

Please complete this submission form for immunization record updates/requests to the Connecticut Department of Public Health. If you tried to access your (or your child’s) immunization record through the CT WiZ Public Portal and your record was not found, or you are requesting an update to your record, or you are requesting an immunization record by mail or fax, please complete the form below and click Submit. Please allow 1-3 business days for processing your submission.

Please complete the fields below with your (or your child’s) information, exactly how you reported it to your provider/clinic, as an exact match in the Connecticut Immunization Information System (CT WiZ) is required.
* Note: A parent can only access an immunization record for their child under age 18. (A child under age 18 cannot access their own record.)
If you have questions on how to complete this form, contact (860) 509-7929 during business hours Monday-Friday 8:30am-4:30pm.
If you have other questions NOT related to immunization record updates/requests, please submit a helpdesk ticket.

* - Required Field

Are you a parent/guardian submitting an immunization record update on behalf of your child (under age 18)?:*

Yes No

Parent/Guardian First Name:*

Parent/Guardian Last Name:*

Parent/Guardian Street:*

Parent/Guardian City:*

Parent/Guardian State: *

Parent/Guardian Zip code:*

Patient First Name:*

Patient Last Name:*

Patient Date of Birth:*

Gender (as shown on your immunization/medical records): *

Is the Patient address the same as the Parent/Guardian?:*

Yes No

Current Street Address:*

City:*

State: *

Zip code:*

Current Email Address:*

Mobile Phone Number:*

Please specify which update(s) you need to submit to CT WiZ?: (Select all that apply)

I have a new email address or cell/mobile phone **Please check that your current email address and cell/mobile phone number that you want to use to access your record is listed in the boxes above. We will update your record in CT WiZ.

My or my child's name is misspelled or needs to be updated, date of birth is incorrect, or gender is incorrect **List update in box below and upload proof of this correction/change

My CT WiZ Immunization Record was missing a dose(s). **Upload proof of vaccinations (such as your CDC vaccine card or proof from your healthcare provider) in order for your missing doses to be added to your CT WiZ record.

I am a parent or guardian but am not listed in CT WiZ in my child's record. **List update in box below and upload proof of custody (ex. birth certificate or proof of guardianship custody.)

I am attaching a Release of Information, Proof of Guardianship or Power of Attorney and proof of my identification below to request an immunization record be mailed or faxed. *As you will not be able to use the CT WiZ Public Portal, please include details on how you wish to receive the record (by mail or fax).

Other/Unsure

Please provide details of your corrections/updates in the box below:

Have you contacted DPH about this request previously?:

By phone

By helpdesk ticket

If known, list who you spoke with:

Please list your ticket number:

Note: For DPH to correct/update your record and to provide an immunization record to you, you must provide proof of identification as listed below. Below you will also be able to upload proof of corrections/updates.

Do you have a valid photo ID?:*

Yes No

Upload your valid photo identification (ID) of the Parent/Guardian.

Upload your valid photo identification (ID).

If you are a parent/guardian making a request on behalf of your child, please attach a valid identification of the parent/guardian.
** If you checked "I am a parent or guardian but am not listed in CT WiZ in my child's record." Please attach a copy of the birth certificate or proof of guardianship.

You can only upload PDF, GIF, PNG, JPG, DOC, DOCX files. *

If you do not have valid photo identification (ID), you must upload/attach any two of the following documents and all documents must have the same name as listed above:

written verification of identity from your employer
current automobile registration
current copy of utility bill showing name and address
current checking account deposit slip stating name and address
current voter registration card

You can only upload PDF, GIF, PNG, JPG, DOC, DOCX files. *

DEPARTMENT OF PUBLIC HEALTH

DPH Submissions System

Information Needed to Access Connecticut Immunization Records

* - Required Field