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VIIRS Application

To monitor and evaluate immunization coverage among children in the territory, the VI Department of Health’s Immunization Program is requiring that parents and guardians complete the Virgin Islands Immunization Registry System (VIIRS) Student Demographic Form for each child in their household. Please complete all information requested and upload a copy of your child’s most up-to-date immunization card (front and back). Once complete, be sure to return the immunization card to your child’s school nurse or the school’s registration personnel to complete the registration process.

Virgin Islands Immunization Registry System (VIIRS) Student Demographic Form 

Name of Facility *
Reporting Period *
Grade *

INSTRUCTIONS: Please PRINT CLEARLY, fill out ALL the REQUIRED DATA and attach a COPY of the student’s immunization card. (If single birth use “1”, if multiple birth (twin, triplet, etc.) use “1” for first born, “2” for second born, etc. 

Birth Status *
Date of Birth *
Child’s First Name *
Middle Initial
Child’s Last Name *
Gender *
Home Telephone Number *
Cell Telephone Number
Physical Address *
City *
Zipcode *
Mailing Address
City
Zipcode
Race *
Other (please specify)
Ethnicity *
Mother’s First Name *
Mother’s Maiden Last Name  *
Work Telephone Number *
Cell phone Number 
Father’s First Name  *
Father’s Last Name  *
Work Telephone Number:  *
Cell phone Number 
Consent *
Immunization Card Upload *
Maximum file size: 1 MB
Upload an image of the back and front of the immunization card
Date *
Signature *
Parent/Guardian (Please Print)
Relationship *

United States Virgin Islands Department of Health