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IMMUNIZATION HISTORY Missing or incomplete immunization information will (Loyola University Chicago)

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IMMUNIZATION HISTORY
Last Name First Middle
Date of Birth (mm/dd/yyyy)
Gender
M F Other
Permanent Address
Have you attended LUC previously? No Yes
If yes, what year? _________
Age
City/State/Country/Zip or Postal Code
LUC ID # if known
To satisfy the immunization requirement, all students must enter their immunizations through LOCUS before submitting a copy of
their immunization record to the Wellness Center.
Missing or incomplete immunization information will BLOCK access to registering OR changing classes.
REQUIRED IMMUNIZATIONS (dates required)
Licensed Provider: Complete Immunization documentation or attach signed physician/school immunizations.
Note: A physical exam is not required
MEASLES-MUMPS-RUBELLA –
2 doses against measles, 2 doses against rubella, and 2 doses against mumps (exempt if born before 1/1/57)
MMR
2 doses at least 28 days apart
AND after 12 months of age
AND both given after 12/31/1967
1
mm/dd/yy
MEASLES (Rubeola)
2 doses at least 28 days apart
AND after 12 months of age
AND both given after 12/31/1967
1
mm/dd/yy
2
mm/dd/yy
OR
2
mm/dd/yy
Positive serum titers are also acceptable proof of immunity
against measles, mumps and rubella.
Required lab report attached.
MUMPS
2 doses at least 28 days apart
AND after 12 months of age
1
mm/dd/yy
2
mm/dd/yy
Documentation of dates of disease IS NOT acceptable
evidence of immunity against measles, mumps or rubella.
RUBELLA
2 doses at least 28 days apart
AND after 12 months of age
1
mm/dd/yy
2
mm/dd/yy
TETANUS-DIPHTHERIA-PERTUSSIS (DPT, DTP, DTaP, Tdap, Td) – no age exemption
At least 3 doses of diphtheria, tetanus and pertussis containing vaccine are REQUIRED.
One MUST
be a Tdap vaccine and have been administered within 10 years of the student’s enrollment date.
1
DTP /
DTaP Tdap Td
mm/dd/y
y
2
DTP / DTaP Tdap Td
mm/dd/y
y
3 within 10 years of enrollment
Tdap
mm/dd/yy
MENINGOCOCCAL CONJUGATE VACCINE - Meningococcal meningitis is a potentially fatal, vaccine-
preventable illness. The Meningococcal Conjugate Vaccine is REQUIRED for all students under the age of 22. A
2
nd
vaccine MUST
be given if the 1
st
vaccine was given before age 16. It is available at the Wellness Center for a fee.
1
mm/dd/yy
2 mm/dd/yy
RECOMMENDED IMMUNIZATIONS (complete if received)
HEPATITIS A
1
mm/dd/yy
2
mm/dd/yy
HEPATITIS B
1
mm/dd/yy
2
mm/dd/yy
3
mm/dd/yy
HPV (Gardasil) HPV (Gardasil 9)
HPV (Cervarix)
1
mm/dd/yy
2
mm/dd/yy
3
mm/dd/yy
VARICELLA
1
mm/dd/yy
2
mm/dd/yy
Had Varicella
(Chickenpox)
Required Healthcare Provider Verification
Provider Name
(print or stamp)
Signature/Title Date
Address
Phone
International Students Only
Tuberculosis skin testing is mandatory and must be done in the United States. If you have been treated for Tuberculosis please bring your English
translated medical records. If you were diagnosed with a positive reaction to tuberculosis documentation is required. TB testing is available at the
Wellness Center for a small fee.
Fax, email (PDF only), or mail your completed immunization form to one of the locations
below: Lakeshore Wellness Center | 6439 N. Sheridan, Suite 310 | Chicago, IL 60626 | FAX: (773)
508-2505 Water Tower Wellness Center | 26 E. Pearson, Suite 250 | Chicago, IL 60611 | FAX:
(773)508-2505 Wellness Center email: wellnesscenter@luc.edu
Rev.04.2020. MD
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Completed 31 July 2021

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