Certificate Of Immunity - Illinois Department Of Health
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1
2Illinois Department of Health
CERTIFICATE OF IMMUNITY
Part I - To be completed by student
___________________________________________________________________________________________________________
Last name (please print)
First
Middle Initial
Student ID#
Sex ٱM ٱF
Date of birth
Home telephone #(
) ___________ - _____________
_____/_____/_____
Semester ٱFall ٱSpring
Year___________
Part II - Attach a Copy of Certificate of Child Health Examination
If you can provide a copy of certificate of health examination to prove ALL immunizations DO NOT FILL OUT PART III.
I authorize Monmouth College to release this immunization record to the Illinois Department of Public Health, or its designated
representative for compliance audits and in the event of a health or safety emergency.
Student’s Signature____________________________________________________________Date__________________________
Part III - To be completed and signed by health care provider* All Dates Must Incl. MO/DAY/YR
Measles (Rubeola)
YES
1) Disease confirmed by physician’s records?
Date of illness ___/____/___
2) Immunity confirmed by blood titer?
Date of test
___/____/___(Attach copy of lab report)
3) Immunization with live virus vaccine?
Date of shot
___/____/___(Must include two dates)
Note: Given in 1968 or later
___/____/___
4) Exemption?
Attach physician’s statement of contraindication
Signature of Physician_______________________________
Rubella (German Measles)
1) Immunity confirmed by blood titer?
Date of test
___/____/___(Attach copy of lab report)
2) Immunization with live virus vaccine?
Date of shot
___/____/___
3) Exemption?
Attach physician’s statement of contraindication
Signature of Physician_______________________________
Mumps
1) Disease confirmed by physician’s record
Date of illness ___/____/____
2) Immunization with live virus vaccine?
Date of shot
___/____/____
3) Exemption?
Attach physician’s statement of contraindication
Signature of Physician_______________________________
Tetanus/Diphtheria
1) Primary series completed?
Date
___/____/____
Note: Must include at least two dates
Date
___/____/____
2) Most recent booster? (Must be within last 10 yrs)
Date
___/____/____
3) Exemption?
Attach physician’s statement of contraindication
Signature of Physician_______________________________
Part IV-Verification
Can be verified by health care provider or official designated record keeping office verifying information.
Name_______________________________Signature____________________________________________Phone#_____________
*Note: Physician licensed to practice medicine in all of its branches (M.D. or D.O.) local health authority, college or university health service or a
Department recognized vaccine provider.
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Parent category: Medical