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NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Immunization for Individuals 19 Years of Age or OlderConsent For Participation in NYSIISFor Individuals 19 Years of Age or Older The New York State Immunization
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01
To fill out a withdrawal of consent form, follow these steps:
02
Obtain the withdrawal of consent form. This form is usually provided by the organization or entity from which you wish to withdraw your consent.
03
Read the form carefully to understand the information required and any instructions provided.
04
Fill in your personal details, such as your name, address, contact information, and any other identifiers requested.
05
Specify the consent you wish to withdraw. Provide details about the specific consent you previously provided, such as the purpose, date, and nature of the consent.
06
Sign and date the form. Ensure that you sign the form with your legal signature and provide the date of withdrawal.
07
Submit the completed form. Follow any submission instructions specified on the form, such as mailing it to a specific address or submitting it electronically.
08
Keep a copy of the form for your records. It's important to retain a copy of the withdrawal of consent form as proof of your withdrawal, if needed in the future.

Who needs withdrawal of consent for?

01
The withdrawal of consent may be needed by individuals who have previously provided their consent for certain activities or purposes but now wish to revoke that consent. This can apply to various situations, such as:
02
- Consent given for marketing communications or promotional materials
03
- Consent given for data collection or processing
04
- Consent given for participation in research studies
05
- Consent given for the sharing of personal information with third parties
06
It is important to consult the relevant organization or entity to understand the specific situations in which a withdrawal of consent is required.
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Withdrawal of consent is for individuals who no longer wish to give permission for their personal information to be used or shared.
Any individual who has previously given consent for their personal information to be used or shared may file a withdrawal of consent.
To fill out a withdrawal of consent, individuals typically need to submit a form or written request to the organization that has their personal information.
The purpose of withdrawal of consent is to protect individuals' privacy rights and give them control over how their personal information is used.
A withdrawal of consent may need to include the individual's name, contact information, any relevant account numbers, and a clear statement of withdrawal.
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