8/12/2019 IIT Immunization Form 02-07-2012

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Student Immunization Verification

revised 02/07/2012 pz

Student Information:

Last Name / Sir Name / Family Name First Name / Middle Name Date of Birth(mm/dd/yyyy)

_______/_______/__________

Student ID (CWID) #

A __ __ __ __ __ __ __ __

E-Mail Address Country of Birth

_________________________

I authorize Illinois Institute of Technology to release this immunization record to the Illinois Department of Public Health (IDPH), or its designated representative forcompliance audits or in the event of a health or safety emergency. All immunization documents submitted to IIT become the property of the University.I understand that,unless required to do so b y law, IIT will not re-release my immunization records to any third part y.

Please complete either Option A or Option B (choose one)

Option A: Attach a copy of your Official Immunization records proving ALL immunizations are current. Skip Option B. Option B: See below Remainder of form to be completed and signed by physician or health care provider.

Student Signature : __________________________________________________ Date: ____________________________

Please keep a copy for your records. Original forms will be destroyed after imaging.

Option B: To be completed and signed by physician or healthcare provider. Please note the following:

Exemptions: The following exemptions will be accepted withofficial supporting documentation.

Positive laboratory (serologic) evidence of immunity via blood(antibody) titer is acceptable proof for Measles, Mumps and Rubella.

Include all lab evidence with copy of lab report.

All documents must be in English or accompanied by a certifiedtranslation.

Medical / Pregnancy Exemptions

Religious Exemptions

Anyone wi th an exemption m ay be excluded fr om campus in theevent of a health emergency, in accordance with pub lic health law.

DIPHTHERIA (DTaP / TDaP / TD)TETANUS LockjawPERTUSSIS Whooping Cough

Given within 10 years of attendance & every 10years as adult, not less than 28 days apart.

International Students are required to provide datesof 3 or more doses.

Tetanus Toxoid (TT) is not acceptable evidence ofimmunity.

1stShot Date

(check one)

DTaP

TDaP

TD___

____/____/_______

2nd

Shot Date(check one)

DTaP

TDaP

TD___

____/____/______

3rdShot Date

(check one)

DTaP

TDaP

TD___

____/____/______

4thShot Date

(check one, if applicable

DTaP

TDaP

TD___

____/____/______

MEASLES Rubeola OR (MMR)

2 doses required, at least 28 days apart, after 12months of age, given in 1968 or later.

1stShot Date

____/____/_______

2nd

Shot Date

____/____/______

ORdiagnosis date

____/____/______

ORpositivebloodtiter with REQUIREDcopy of lab report.

MUMPS OR (MMR)

2 doses required, after 12 months of age.

1stShot Date

____/____/_______

2nd

Shot Date

____/____/______

ORdiagnosis date

____/____/______

OR positivebloodtiter with REQUIREDcopy of lab report.

RUBELLA German Measles OR (MMR)

1 dose required, after 12 months of age.

1stShot Date

____/____/_______

2nd

Shot Date

____/____/______

A history of Rubella is notacceptable evidence ofimmunity.

OR positive bloodtiter with REQUIREDcopy of lab report.

TUBERCULOSIS (TB)

Screening via PPD (Purified Protein Derivative) orQuantiFERON -TB Gold, required for InternationalStudents.

Tuberculin Test Given

QuantiFERON

PPD skin test__

____/____/_______

Test Read Date

____/____/______

Result (level ORmm)

_____ level

_____ mm

Interpretation

PositiveNegative

Tuberculin Results / Chest X-RayReport required as attachment if tuberculin test isinterpreted as positive. Results must be within thelast 12 months, indicating actual mmof induration,(transverse diameter of zero if no induration) or level.

Return completed form to: IIT Student Health & Wellness Cente10 W. 35

thStreet, IIT Tower Suite 3D9

Chicago, IL 6061Phone 312-567-7550 Fax 312-567-570

Email student.health@iit.ed

Webhttp://www.iit.edu/student_health

Physician or public health official verification - I verify to the best of my knowledge that the above immunization information is correct.

Physician Name (clinic stamp or seal REQUIRED): Date (mm/dd/yyyy)

______/______/___________

Physicians Signature:

This form must be completed and returned with applicable attachments before the student is allowed to register.

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