For those who will receive the vaccination on campus

What to Bring
IMPORTANT: There will be NO space to fill in forms at the vaccination site. You need to bring the COMPLETED
forms with you. Also we will not provide any extra copies of the forms. You are expected to print them out on your
own. Although you must fill in the JAPANESE VERSIONS of these forms, you can fill them in in English.
1. STUDENT ID
2. Prevaccination Screening Questionnaire for COVID-19 vaccine (予診票)*
3. Record of Vaccination for COVID-19 （新型コロナワクチン接種記録書）*
4. Black inked pen (Pencil and erasable pen are NOT accepted)
5. Passport (international students only)

Record of Vaccination for COVID-19

In order to properly document that you have received the vaccine, the “Record of
Vaccination for COVID-19 (コロナワクチン接種記録書)” is very important, as it can
be used as a proof of vaccination.
Please keep this form (Japanese version) in a safe place and do not lose it (it
cannot be reissued). You should bring this when you receive the 2nd does.

Submit the Coupon to the IEO

Even though you receive the vaccine on campus, you will still be sent a Vaccination Coupon (接種券) from the city
or ward where your address is registered when they start their own vaccination program. Once you receive this
coupon, you should submit it to the International Exchange Office. We will forward it to your registered
city/ward office, who will officially register your record of receiving the vaccine.

Sample of the coupon↓

We will accept it by mail as well.

Where to send:
Tokyo International University
International Exchange Office
1-13-1, Matobakita, Kawagoe, Saitamata
350-1197

Official Certificate of the Vaccination

If you would like to have an official certificate that shows you have received a vaccination, you need to contact
your local city/ward office. Please be advised that we do not know how long it will take for the certificate to be
issued.