Immunization Information Form

ADVERTISEMENT

CAMPUS BOX 1055
PHONE: (618) 650-2842
0222 STUDENT SUCCESS CENTER
FAX:
(618) 650-5839
EDWARDSVILLE IL 62026-1055
cougarcare@siue.edu
SOUTHERN ILLINOIS UNIVERSITY EDWARDSVILLE
IMMUNIZATION INFORMATION FORM
PART I: GENERAL INFORMATION – TO BE COMPLETED BY STUDENT. PLEASE PRINT.
_______________________________
_______________________________
___________
Last Name
First Name
Middle Initial
_______________________________
_______________________________
SIUE ID number
Date of Birth (MM/DD/YY)
First semester at SIUE: YEAR _____ Fall _____ Spring _____ Summer _____
International Student: Yes _____ No _____
PART II: IMMUNIZATION INFORMATION
COMPLETE DOCUMENTATION OR ATTACH SIGNED IMMUNIZATIONS
IMMUNIZATIONS REQUIRED BY ILLINOIS LAW (dates required)
Licensed Provider: Complete Immunization documentation or attach signed physician/school immunizations.
1
1
MEASLES (Rubeola)
2 doses at least 28 days
Positive serum titers are also
mm/dd/yy
apart AND after 12
acceptable proof of immunity
2
MMR
months of age AND both
against measles, mumps, and
2 doses at least 28 days apart
given after 12/31/1967
mm/dd/yy
rubella.
mm/dd/yy
AND after 12 months of age
OR
2
1
AND both given after
MUMPS
Required
after 12 months of age
12/31/1967
mm/dd/yy
lab report
1
RUBELLA
attached
after 12 months of age
mm/dd/yy
mm/dd/yy
TETANUS-DIPHTHERIA-PERTUSSIS (DPT, DTP, DT, DTaP, Td, Tdap)
Domestic students: record of at least one tetanus/diphtheria shot within 10 years of enrollment is required.
International students: record of at least three tetanus/diphtheria shots, one within 10 years of enrollment, is required.
1
Td
Tdap
DTP
2
Td
Tdap
DTP
3
Td
Tdap
DTP
mm/dd/yy
mm/dd/yy
mm/dd/yy
All incoming i
nternational students will complete a TB risk assessment. At risk students will be screened with a TB blood test
This must be completed by the 10th day of class at SIUE Health Service.
(Quantiferon-gold).
OTHER IMMUNIZATIONS (RECOMMENDED) -- The following are optional immunizations, but are strongly recommended for all students.
1
MENACTRA
MENOMUNE
MENINGOCOCCAL
mm/dd/yy
2
1
HEPATITIS A
mm/dd/yy
mm/dd/yy
2
3
1
HEPATITIS B
mm/dd/yy
mm/dd/yy
mm/dd/yy
1
2
3
HPV
mm/dd/yy
mm/dd/yy
mm/dd/yy
Health Care Provider verifying that immunizations were given.
Name (print):
_________________________________
Signature:
___________________________
Address:
_________________________________
Date:
___________________________
_________________________________
Telephone:
___________________________
_________________________________
FOR SIUE USE ONLY: Compliant _____ Non-Compliant _____
Immunizations Needed (if N/C): ______________________
Hold Checked _____ Hold Lifted ______ Secure Message _____
Discussed w/Student: In Person or By Phone _____________
Exemptions: Medical _____ Religious _____ Age _____
Verified/Entered by: ___________ Date: _______________

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go