Immunization Compliance Form - Siu Student Health Services

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IMMUNIZATION COMPLIANCE FORM

Please complete “Contact Information” AND 1) have a Licensed Health Care Provider complete the rest of the form OR

2) submit required immunization records. Send to: Student Health Services, Immunization Compliance, 374 East Grand

Avenue, MC 6740, Carbondale, Illinois 62901. Fax forms to (618) 453-4452 or email forms to immunizations@siu.edu.

Questions? Please call (618) 453-4326.

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CONTACT INFORMATION

Student's Last Name

Student's First Name

Middle Initial

Dawg Tag

Home Address (permanent)

Home Phone

(

)

City/State/ZIP or Postal Code

Cell Phone

(

)

Date of Birth: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)

Citizenship  U.S.A  Other: (specify)

First Semester at SIU Carbondale  Fall  Spring  Summer

__________ year

INTERNATIONAL STUDENTS: Please call (618) 453-4326 to schedule your required Tuberculosis screening when you arrive on the SIU Carbondale Campus.

Please bring a copy of this completed form. Country of Birth ___________________________________________

This section must be completed by a Licensed Health Care Provider.

REQUIRED IMMUNIZATIONS

(Illinois Law, Public Act 85-1315)

MEASLES-MUMPS-RUBELLA

(2 measles, 1 mumps (2 recommended), 1 rubella)



(Rubeola)

Documentation of dates

MMR

MEASLES

of disease serves as accept-

2 doses at least 28 days apart

2 doses at least 28 days apart AND after

mm/dd/yy

able evidence of immunity

AND after 12 months of age

12 months of age AND both given after

against measles and mumps,

AND both given after

12/31/1967.

but not rubella.

12/31/1967

mm/dd/yy



Positive serum titers are also acceptable proof of

MUMPS



Required lab

immunity against measles, mumps, and rubella.

after 12 months of age

mm/dd/yy

reports attached.



RUBELLA



Required lab reports attached.

after 12 months of age

mm/dd/yy

TETANUS-DIPHTHERIA-PERTUSSIS

(DPT, DTP, DT, DTaP, Td, Tdap) 1 required in last 10 years (International: 2 additional required)

 DTP  Td  Tdap

mm/dd/yy

RECOMMENDED IMMUNIZATIONS

 Menactra  Menveo

 MENINGITIS*

 Meningococcal (unspecifi ed)

mm/dd/yy

 HEPATITIS B

mm/dd/yy

 HPV (Gardasil)

 HPV (Cervarix)

mm/dd/yy



Date disease diagnosed and certi-

Lab test proving immunity (attach

 VARICELLA

____/____/____

mm/dd/yy

fi ed by physician

lab report)

*NOTE: Meningococcal Meningitis is a potentially fatal, vaccine-preventable illness. We recommend the Meningococcal Conjugate Vaccine for all students 21

and younger. A second vaccine should be given if the fi rst vaccine was given before age 16. Th is vaccine is available at the Student Health Center.

VERIFICATION REQUIRED BY LICENSED HEALTH CARE PROVIDER

FOR SIU SHS use only

Date Exemption ends:

Signature

Provider Name

___/___/___

(please print)

allergy



Address

Date