Please complete this submission form if you have 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 your immunization record by mail or fax and need to submit proof of identification to Connecticut DPH.

  • When using the CT WiZ Public Portal to access your (or your child’s) vaccination record, the information entered must be an exact match with the CT immunization information system to be successful.
  • Please complete the fields below with your (or your child’s) information, exactly as it should read in your (or your child’s) existing record in the Connecticut Statewide Immunization Information System (CT WiZ).
  • * Note: A parent can only access an immunization record for their child under age 18.
  • For any questions on how to complete the form, please contact (860) 509-7929 during business hours Monday-Friday 8:30am-4:30pm.
* - Required Field
 Yes    No  













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 Using the CT WiZ secure online Public Portal (1 business day for processing your updates) 
 By Mail (1-3 business days for processing your updates plus mail time) 
 By Fax (1-3 business days for processing your updates) 



I have a new email address or cell phone **list update in box below

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

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.)

My CT WiZ Immunization Record was missing a dose(s).

Other/Unsure

Note: Please also report these updates to your primary care provider/pediatrician at your next visit.

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


 By phone 
 By helpdesk ticket  




  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.

 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.