Fax or mail the completed form to your local Maternal and Child Health Consortia (MCHC) office or the Vaccine Preventable Disease Program, at the address listed above. Information for the local MCHC for your county can be found at https://www.njiis.nj.gov/njiis/jsp/trainingschedule.jsp.How to obtain consent to participate in njiis?
CONSENT TO PARTICIPATE - Retain a copy of this form in the Medical Record - Registrant Information Parent/guardian information (if NJIIS Registrant is a minor) Registrant Name (Print) Name (Print) Date of Birth Address Country of Birth City, State, Zip Code Name of Primary Health Care Provider Relationship to RegistrantWhat is the medical record number for njiis?
Name of NJIIS Enrollment Site Registry ID Number Medical Record Number - Retain a copy of this form in the Medical Record - IMM-32 JUL 12 Title IMM-32, Consent to Participate, NJIIS Author Elaine White Keywords IMM-32, consent to participate, NJIIS, Immunization, vaccine preventable disease programWhat is the NJ Immunization Information System ( njiis )?
New Jersey Immunization Information System (NJIIS) Information for Adults What is NJIIS? A free, confidential, population-based online system, operating since 1997, that collects and consolidates vaccination data for New Jersey’s children, adolescents, and adults. NJIIS is managed by the New Jersey Department of Health, Vaccine Preventable