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 for
compliance 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,
unl ess required to do so by l aw, IIT will not re-release my immunizati on 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 health
care provider. Please note the following:

Exemptions: The following exemptions will be accepted with
official 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 certified
translation.



Medical / Pregnancy Exemptions

Religious Exemptions

Anyone with an exemption may be excluded from campus in the
event of a health emergency, in accordance with public health law.

DIPHTHERIA (DTaP / TDaP / TD)
TETANUS Lockjaw
PERTUSSIS Whooping Cough
Given within 10 years of attendance & every 10
years as adult, not less than 28 days apart.

International Students are required to provide dates
of 3 or more doses.

Tetanus Toxoid (TT ) is not acceptable evidence of
immunity.


1
st
Shot Date
(check one)

DTaP

TDaP

TD___

____/____/_______

2
nd
Shot Date
(check one)

DTaP

TDaP

TD___

____/____/______

3
rd
Shot Date
(check one)

DTaP

TDaP

TD___

____/____/______

4
th
Shot Date
(check one, if applicable)

DTaP

TDaP

TD___

____/____/______

MEASLES Rubeola OR (MMR)

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


1
st
Shot Date

____/____/_______

2
nd
Shot Date

____/____/______

OR diagnosis date

____/____/______

OR positive blood
titer with REQUIRED
copy of lab report.
MUMPS OR (MMR)

2 doses required, after 12 months of age.



1
st
Shot Date

____/____/_______

2
nd
Shot Date

____/____/______

OR diagnosis date

____/____/______

OR positive blood
titer with REQUIRED
copy of lab report.

RUBELLA German Measles OR (MMR)

1 dose required, after 12 months of age.



1
st
Shot Date


____/____/_______

2
nd
Shot Date


____/____/______


A history of Rubella is not
acceptable evidence of
immunity.

OR positive blood
titer with REQUIRED
copy of lab report.
TUBERCULOSIS (TB)
Screening via PPD (Purified Protein Derivative) or
QuantiFERON-TB Gold, required for International
Students.

Tuberculin Test Given
QuantiFERON
PPD skin test__

____/____/_______

Test Read Date





____/____/______

Result (level OR mm)

_____ level

_____ mm

Interpretation

Positive

Negative

Tuberculin Results / Chest X-Ray
Report required as attachment if tuberculin test is
interpreted as positive. Results must be within the
last 12 months, indicating actual mm of induration,
(transverse diameter of zero if no induration) or level.


Return completed form to: IIT Student Health & Wellness Center
10 W. 35
th
Street, IIT Tower Suite 3D9 1
Chicago, IL 60616
Phone 312-567-7550 Fax 312-567-5702
Email student.health@iit.edu
Web http://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.