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Immunization Demographic & Records Transfer (TennIIS)
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Educational institutions and daycare/preschool facilities require students to show proof of immunization against certain preventable communicable illnesses. The State of Tennessee currently provides immunization records on an official certificate issued by local health departments or by primary care providers who participate in the online immunization information system. All new immunization records must be MANUALLY TRANSCRIBED by department staff. Please allow 1-2 business days for processing. Submissions received after 4:00pm will be processed the next business day.
Parent/Guardian/Caregiver Information:
Guardian First Name:
*
Guardian Last Name:
*
Street Address:
*
Apt./Lot#:
City:
*
State:
*
Zip code:
*
County:
*
Cheatham
Davidson
Dickson
Hickman
Marshall
Maury
Robertson
Rutherford
Sumner
Williamson
Wilson
Other TN county
Out of state
Cell phone:
*
Home/Alternate Phone:
Email address:
*
CHILD/STUDENT INFORMATION:
Student first name:
*
Student middle initial:
Student last name:
*
Student date of birth:
XX/XX/XXXX
*
Gender:
*
Male
Female
Ethnicity:
*
Not hispanic
Hispanic
Race:
*
White
Black
Asian
American indian
Hawaiian/pacific islander
Multiracial
Other
School grade entering:
*
Daycare/Preschool
Headstart
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
Has your child ever had the Chickenpox disease (varicella)?
*
Yes
No
IF YES, please provide the estimated date of illness:
Are you relocating from outside of the continental United States?
*
Yes
No
IF YES, please provide the territory/state/country you are coming from:
How would you like to receive your Tennessee Certificate of Immunization?
*We do not fax certificates to schools or guardians.
*
WALK-IN: Please call and I will pick up the certificate
US MAIL: Please mail the certificate to the address listed above
Please UPLOAD your child's immunization records in PDF format. Please note, we MUST be able to clearly read the documents. Blurry or poor quality uploads will not be used.
*
Convert to PDF?
(DOC, DOCX, XLS, XLSX, TXT)
By providing your digital signature you are agreeing to the following:
I certify that I am the legal guardian or person legally designated to make healthcare decisions on behalf of the above named child and that all information provided is true and accurate to the best of my knowledge. I authorize the Williamson County Health Department to access, update and or create the above named child's record for official use and release the record in-person, by mail or email.
Legal Guardian Full Legal Name (digital signature)
*
* indicates required fields.
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