Student Health and Wellness Center

10 W 35th Street - 3D9-1 - 312-567-7550

Required Immunization Information
CERTIFICATE OF COMPLIANCE WITH IMMUNIZATION REQUIREMENTS FOR INSTITUTIONS OF HIGHER LEARNING IN ILLINOIS
It is mandatory for students born on or after January 1, 1957 to document immunity to tetanus and diphtheria, measles, mumps,
and rubella prior to registration.

Part I—To be completed by Student (Please Print)

Family/Last/Surname First Name Student Identification Number (example: A20300000)

A
Age Date of Birth (month/day/year) Country of Birth Semester of Entrance: Fall Spring Summer
_______ ______ / ______/ _________
If found to be in violation of the IIT Code of Conduct, students may face sanctions including fines, service hours and restricted student status. I under-
stand that I will be subject to the campus conduct process if the University determines that I have falsified immunization documents or forged signa-
tures on any documentation. I authorize IIT to release this immunization record to the Illinois Department of Public Health (IDPH), or its designated
representative, for compliance audits and in the event of a health or safety emergency.
Student Signature: ____________________________Email:________________________________________ Date:____________

Part II—To be completed by Health Care Provider—Please Note: Medical exemptions require supporting documentation.
MMR (Measles, Mumps, Rubella)
Two doses required at least 28 days apart for students born after 1957. If vaccine dates are not available, immunity may be confirmed by blood titer.
Laboratory copy with blood titer values or a reference range must be attached.
MMR Dose 1 (given on or after the first birthday): ____/_____/____ MMR Dose 2: ____/_____/____
month/day/year month/day/year
If individual vaccines were received for Measles, Mumps, and Rubella, please complete the following dates (month/day/year):
Measles (Rubeola) Vaccine #1: ____/_____/____ Mumps Vaccine #1: ____/_____/____ Rubella (German Measles) Vaccine #1: ____/_____/____
Measles (Rubeola) Vaccine #2: ____/_____/____ Mumps Vaccine #2: ____/_____/____ Rubella (German Measles) Vaccine #2: ____/_____/____

Meningococcal ACYW (Meningitis)

1 dose required for Anyone under the age of 22. All students shall show proof of having at least one dose of the meningococcal conjugate ACYW vac-
cine on or after 16 years of age.
#1 ______/______/______ #2 ______/______/______
month/day/year month/day/year
TD/DTP/DTAP (DTP, DTaP, DT, Td, or Tdap)
3 doses required with one dose being Tdap and one dose (any combination DTP, DTaP, DT, Td, or Tdap) having been administered within the past 10
years.

#1 #2 #3 Most Current Booster (given within past 10 years)

____/_____/____ ____/_____/____ ____/_____/____ ____/_____/____
month/day/year month/day/year month/day/year month/day/year

TB Blood Test (Tuberculosis) for International Students ONLY (Must be done within 2-4 weeks before arrival to the U.S.)
Screening through Interferon-Gamma Release Assay (IGRA)—(QuantiFERON Gold or T-SPOT). IGRA results must be attached. Results will
not be accepted without proper documentation **IF positive IGRA, a Chest X-Ray is required.
QuantiFERON or T-SPOT Date: _____/_____/_____ *IGRA results must be attached
month/day/year
Clinic Stamp/Seal Signature of Health Care Provider Completing the above information
Required Provider’s Signature/Title: ________________________________________________ Date: ______________________

Provider’s Printed Name: ____________________________________________________________________________

Address: __________________________________________________________________________________________

Telephone: ________________________________________ Fax: ____________________________________________

 Student Health and Wellness Center
Required Immunization Information Instructions

According to the IL State College Student Immunization Act (110 ILCS 20), Illinois Institute of Technology
requires that this document be completed and returned prior to the first day of the semester in which a
student is first enrolled. This requirement applies to all newly admitted students, including new graduate
students, readmitted students, and transfer students.
Note: Missing or incomplete immunization information will RESTRICT access to registering OR changing classes.

• A licensed healthcare provider must complete Part II of the immunization form. Or seek and submit
immunization records from your high school transcript, military records, other past university, or State issued
records.
• All dates must include month/day/year.
• Keep a copy of this form for your personal health records or in the event it is not received by the IIT Student
Health & Wellness Center.
• For additional immunization information, go to: http://www.iit.edu/shwc
• Exemptions*: Anyone with a vaccine exemption may be excluded from the University/College in the event of
a Measles, Mumps, Rubella or Diphtheria outbreak in accordance with public health law.
*Medical Contraindications: Please go to: http://www.iit.edu/shwc and submit a Medical Exemption
Form.
*Pregnancy or Suspected Pregnancy: Please go to: http://www.iit.edu/shwc and submit a Medical
Exemption Form.
*Religious Exemptions: Please go to: http://www.iit.edu/shwc and submit a Religious Exemption Form.

Students who are not properly immunized or who do not have proof of immunization may receive the
required immunizations at the Student Health and Wellness Center
Please go to: http://www.iit.edu/shwc for more information.

IIT Student Health and Wellness Center, 10 W 35th St, Suite 3D9-1, Chicago, IL 60616
Phone: (312) 567-7550 Fax: (312) 567-5702 Email: student.health@iit.edu Web: www.iit.edu/shwc