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IMMUNIZATION HISTORY Phone (217) 333-2702 (M-F) (University of Illinois at Urbana-Champaign)

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IMMUNIZATION HISTORY Phone (217) 333-2702 (M-F)
1109 S. Lincoln Ave. Urbana, IL 61801 Fax (217) 244-1278
Last Name First Middle
University Identification Number
Home Address
Preferred Phone
( )
Alternate Phone
( )
City/State/Country/Zip or Postal Code
E-mail Address
Date of Birth (mm/dd/yyyy)
Age
Gender
M F Other
Enrollment term/year
FA___ SP___ SU___
Person to Notify in an Emergency
Name:
Relationship
Contact Phone
( )
Address of Emergency Contact (including City/State/Country/Zip or Postal Code)
Alternate Phone
( )
REQUIRED IMMUNIZATIONS (dates required)
Licensed Provider: Complete Immunization documentation or attach signed physician/school immunizations.
◼ MEASLES-MUMPS-RUBELLA – 2 shots against measles, 2 shots against rubella, and 2 shots against mumps
MMR (strongly recommended) **
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.
**Individuals born before 1957 are exempt from MMR
vaccine documentation.
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, DT, DTaP, Td, Tdap) –
At least 3 doses of diphtheria, tetanus and pertussis containing vaccine are REQUIRED. One dose MUST be Tdap.
The last dose of vaccine (DPT, DTP, DT, DTaP, Td, Tdap) must have been administered within 10 years of the student’s enrollment date.
1 (record first shot here)
DTP / DTaP Tdap Td mm/dd/yy
2
DTP / DTaP Tdap Td mm/dd/yy
3
Tdap Td mm/dd/yy
◼ MENINGOCOCCAL CONJUGATE VACCINE –Students between the ages of 16-21 must have one dose of Menactra, Menveo,
Nimenrix or Aramen on or after their 16
th
birthday. Students age 22 and over are not required to receive the vaccine. Meningococcal-B
vaccine does not meet this requirement.
Menactra/Menveo mm/dd/yy ____________ mm/dd/yy ____________ Other: Vaccine name ______________________ 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 (Cervarix)
1
mm/dd/yy
2
mm/dd/yy
3
mm/dd/yy
MENINGITIS B
1 Bexsero Trumenba
mm/dd/yy
2 Bexsero Trumenba
mm/dd/yy
3 Bexsero Trumenba
mm/dd/yy
VARICELLA
1
mm/dd/yy
2
mm/dd/yy
Had Varicella
(Chickenpox)
COVID-19: Pfizer Moderna J&J Janssen
Other _
1
mm/dd/yy
2
mm/dd/yy
Required Healthcare Provider Verification: Vaccine dates must be on or prior to provider verification date.
Provider Name
(print or stamp)
Signature Date
Address
Phone
TO SUBMIT FORM: Students: Upload to MyMcKinley.illinois.edu Providers: Fax or Mail to McKinley Health Center
Submission Deadlines: Fall - July 1, Spring - December 1, Summer - April 1 04/21/21:ms
This section must be completed by a Licensed Health Care Provider.
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IMMUNIZATION HISTORY Phone (217) 333-2702 (M-F) (University of Illinois at Urbana-Champaign)

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Completed 9 May 2022

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