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Petition for Modification (P4M) Form
This form is for requesting modifications or changes to a child’s MCIR record. Support documentation for the requested change(s) must accompany this form. Support documentation includes, but is not limited to: a copy of the child’s MI green immunization card, a copy of a parent’s signature card, or a copy of clinic’s immunization record. A copy of the MCIR record is not considered sufficient support documentation.
 Regional Policy
Petition for Modification Form
Find A Child (FAC)
Before a provider office may add a MCIR record to the registry for any child born in Michigan, January 1, 1994 to present, the office must submit and FAC form requesting a regional search of the registry data for an existing record.
Find A Child Information
Find A Child Form
Opt-Out (O-O) Form
Parents are informed of the MCIR via the Vaccine Information Statements received at the time of immunization administration; however, a parent may request their child’s MCIR record be closed off / “opted-out” of the registry. The proper form must be completed and submitted to the regional office before a MCIR record can be “opted-out” of the registry.
Opt-Out Form
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