Please complete the following form to submit your child's immunization information.
If your child attends a licensed child care centre, provide a copy of the immunization information to the child care operator.
Required fields are marked with an asterisk ( * )
* Did you receive an "IMMUNIZATION RECORD UPDATE FORM"?
Year Receive Record Update Form:
Month Receive Record Update Form:
Day Receive Record Update Form:
* Did you receive an "Order for Suspension from Attendance at School" notice?
Year Receive Notice Form:
Month Receive Notice Form:
Day Receive Notice Form:
* Does your child live in Ottawa or attend a licensed child care or school in Ottawa?
(If your child lives and/or attends a licensed child care or school OUTSIDE of Ottawa, please contact your local health unit.)
* Family Name:
* Given Name:
* Does the child have an Ontario Health card?
Ontario Health Card Number:
X X X X •
X X X •
(last 3 digits)
Is the child enrolled in school or a licensed child care facility?
School/Licensed Child Care Facility:
* Parent's/Guardian's Name:
* Daytime Tel. Number:
Alternate Tel. Number:
No e-mail address available / No e-mail please
If you provide an email address we will send you an email response, within 3 working days, confirming that your child’s record is now up to date or is still missing information.
Doctor's/Clinic's Tel. Number:
Child Care and Early Years Act:
Personal health information is collected on this form to create an immunization record and facilitate communications with the parent/guardian and physician regarding the immunization requirements.
Immunization of School Pupils Act:
Personal health information about the pupil is collected on this form to create an immunization record and will be used to facilitate communications with the parent/guardian and physician regarding the immunization requirements.
Ottawa Public Health,
100 Constellation Dr.,
Ottawa ON K2G 6J8
Mail-Code: 26-44Fax: 613-580-9660
Phone 613-580-6744 Monday to Friday, 9 am to 4 pm
Questions regarding this collection may be addressed to:
Supervisor, Vaccine Preventable Diseases Program,