KYIR School Permission Slip
Kentucky has a statewide immunization registry (KYIR) that medical practices use to help keep track of their patient’s immunizations. They use this system to record vaccines given to patients and to access information about their patients’ immunization histories, including vaccines given at other medical offices. KYIR makes it easy to keep track of a patient’s immunization status, even if the patient visits more than one medical practice. It also helps ensure doctors and nurses give the right vaccines at the right time, and allows them to remind their patients when vaccines are due or overdue.

The information in KYIR is CONFIDENTIAL- only authorized users may access the system. Authorized users include health departments, medical practices, schools, childcare facilities, WIC Programs, and health care plans.

Some records in KYIR may be incomplete or missing because an immunization was given in another state, or because the medical practice did not enter it into the system. Your child’s school wishes to help improve our community’s records by providing missing immunization information to KYIR, but requires your permission to do so, in accordance with the Family Educational Rights and Privacy Act (FERPA).

By completing this form, you can make your child’s immunization history more complete, helping to ensure appropriate and timely future immunization.

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Please complete this form if you agree to grant permission for your child’s school to provide your child’s immunization history to KYIR. This may include creating a new record, or updating an existing record. Please submit a separate form for each child.
Child's Full Name: *
Child's Date of Birth: *
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Parent's First and Last Name: *
Parent's Telephone Number: *
Today's Date: *
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