Dear Student, IMMUNIZATION RECORD INSTRUCTIONS

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1 Dear Student, Welcme t the University f Chicag! The State f Illinis and University regulatins require students t prvide prf f required immunizatins prir t registratin fr classes. In rder t cmplete this requirement, yu must fllw the steps belw. IMMUNIZATION RECORD INSTRUCTIONS Step 1: Print the immunizatin frm (pages 3 and 4) Cmplete the demgraphic (tp) sectin AND 1) have a licensed health care prvider cmplete the rest f the frm OR 2) gather required immunizatin recrds (see step 2). Step 2: Get yur recrds Acceptable frms f dcumentatin include schl immunizatin recrds, clinic/hspital recrds, Internatinal Certificate f Vaccinatins, r ther fficial dcumentatin f yur vaccinatin histry. Please make sure that the recrd is in English; translatins f nn-english dcuments must be certified. If yu have nt received these immunizatins, please make every effrt t btain them befre arriving n campus. If yu are unable t receive them prir t arriving n campus, please call Student Health Service at (773) t schedule an appintment. Step 3: Submit cmpleted immunizatin frm and recrds Uplad yur cmpleted dcumentatin t the Immunizatin Prtal. The Immunizatin Prtal will indicate what immunizatins yu may still need. Yu may submit questins abut cmpliance thrugh the Immunizatin Prtal. Thank yu fr yur attentin t this imprtant matter. Student Health Service 1

2 Students are required t prvide dcumentatin f the fllwing vaccines: MEASLES, MUMPS, RUBELLA (MMR) Vaccines fr MMR must be given n r after 12 mnths f age (n r after the student s first birthday). Tw (2) Measles (Rubela) vaccines, separated by at least 28 days, are required. Fr measles vaccines given befre 1968, prf must be submitted that a live-virus vaccine was administered. Histry f disease is nt acceptable as prf f immunity fr Rubella. Titers are required fr prf f immunity in thse wh have a histry f disease. Students brn n r befre January 1, 1957, will nt have t prvide immunity fr MMR. TETANUS/DIPTHERIA/PERTUSSIS (DPT, DTP, DT, DTaP, Td, r Tdap) All students must shw prf f vaccinatin f three (3) dse dates fr Tetanus/Diphtheria/Pertussis immunizatin. One dse must be a Tdap (tetanus, diphtheria and acellular pertussis) vaccine. One dse must have been given within 10 years f the first day f the quarter yu start at the University f Chicag. MENINGOCOCCAL (Menactra MCV4, Menmune MPSV4, Menve) Required fr all new students under the age f 22. One dse must have been given n r after 16th birthday. Imprtant Ntes: A licensed healthcare prvider must cmplete the immunizatin frm. A healthcare prvider is a physician licensed t practice (M.D. r D.O.), a licensed nurse, r a public health fficial. English: All immunizatin frms and cpies f labratry reprts must be submitted in English. Translatins f nn-english dcuments must be certified. It is acceptable t have an English translatin f the dcuments certified as accurate by a member f the University cmmunity wh is fluent in the dcument s riginal language. Exemptins: The fllwing exemptins may be allwed. Anyne with a vaccine exemptin may be excluded frm the University in the event f a Measles, Mumps, Rubella, r Diphtheria utbreak in accrdance with public health law. Medical cntraindicatins: a written, signed, and dated statement frm a physician stating the vaccine that is cntraindicated, the nature, and duratin f the medical cnditin that cntraindicates the vaccine(s). This statement will nt be accepted if it des nt meet the standards f care at the University f Chicag Hspitals. Submit this statement t the Student Health Service Immunizatin Prgram at sccimm@uchspitals.edu. Pregnancy r suspected pregnancy: a signed statement frm a physician stating the student is pregnant r pregnancy is suspected. Pregnancy exemptins are applicable nly t Measles, Mumps, and Rubella requirements. Submit this statement t the Student Health Service Immunizatin Prgram at sccimm@uchspitals.edu. Age exemptin: Persns brn befre January 1, 1957, are cnsidered immune t Measles, Mumps, and Rubella. Religius exemptin: a written, signed, and dated statement by the student detailing the student s bjectin t immunizatin n religius grunds. Request fr religius exemptins will be frwarded fr review and nly be granted by the Registrar. Submit this statement t the University Registrar at registrar@uchicag.edu. Questins? sccimm@uchspitals.edu r call (773)

3 PART I STUDENT INFORMATION STUDENT IMMUNIZATION RECORD FORM Student ID#: First Quarter Attending (circle): Fall / Winter / Spring / Summer Last Name: First Name: MI: Date f Birth: Sex: Phne Number: Parts II - IV are t be cmpleted by a healthcare prvider. All dates must include MONTH, DAY, and YEAR. PART II MEASLES, MUMPS, RUBELLA Students brn n r befre January 1, 1957, will nt have t prvide immunity fr MMR. MMR #1 Date f Vaccine Must be given n r after 12 mnths f age/first birthday MMR #2 Date f Vaccine Must be given at least 28 days after MMR #1 OR If individual vaccines were received fr Measles, Mumps, and Rubella, please cmplete the fllwing: Measles (Rubela) Vaccine Date f Vaccine # 1 Date f Vaccine # 2 Rubella (German measles) Vaccine Date f Vaccine # 1 Date f Vaccine # 2 Mumps Vaccine Date f Vaccine # 1 Date f Vaccine # 2 If prf f vaccine cannt be prvided, a student must btain a bld titer t cnfirm immunity f any f the abve. A cpy f the labratry test in English must be submitted. 3

4 Student ID#: First Quarter Attending (circle): Fall / Winter / Spring / Summer PART III TETANUS/DIPHTHERIA/PERTUSSIS (DPT, DTP, DT, DTAP, TD, OR TDAP) All students must shw prf f vaccinatin f three (3) dse dates fr Tetanus/Diphtheria/Pertussis immunizatin. One dse must be a Tdap (tetanus, diphtheria, and acellular pertussis) vaccine. One dse must have been given within 10 years f the first day f the quarter the student starts at the University. Tetanus Txid vaccine is nt acceptable in fulfilling this requirement. Date f TDAP Vaccine AND Date f DPT,DTP,DT,DTap, Td, r Tdap Vaccine Date f DPT,DTP,DT,DTap, Td, r Tdap Vaccine PART IV MENINGOCOCCAL VACCINE (MENACTRA MCV4, MENOMUNE MPSV4, MENVEO, OR MENINGOCOCCAL) Required fr all new students under the age f 22. One dse must have been given n r after 16th birthday. Date f Vaccine HEALTHCARE PROVIDER CERTIFICATION Prvider(s) Signature: Prvider(s) Printed Name: Address: Phne Number: 4

5 Medicat Cmpliance Services COMPLIANCE SERVICES QUICK REFERENCE SHEET FOR STUDENTS Cmpliance Services allws students t enter their wn immunizatin infrmatin int a secure nline student prtal. This infrmatin is verified and apprved by a health administratr wh can track cmpliance r lack f cmpliance and reprt back t the student thrugh secure messaging. Cmpliance Services makes it easy t check that student requirements are satisfied and generate reprts which track and mnitr student immunizatin activity. This sheet is a quick guide t sme cmmn issues that arise fr students using Cmpliance Services. Requirements Each student is respnsible fr understanding the requirements f their institutin. Each student is respnsible fr meeting the submissin deadlines set by their institutin and understanding that they may be blcked frm registratin in subsequent quarters if they d nt satisfy requirements. All supprting dcumentatin must include a student s full name (first and last), their student ID, and their birthdate fr verificatin purpses. Accessing the Cmpliance Services Management System Using any brwser n a cmputer r mbile device, g t Students will use their University Credentials (CNetID) t access the nline systems fr Cmpliance Services. Fr any questins yu have regarding these credentials r frgtten passwrd, please visit cnet.uchicag.edu. Access Prblems If there is any difficulty accessing Cmpliance Services, please cntact yur Area Dean f Students. If yu encunter prblems uplading dcuments, please send an t cmplianceservices@medicat.cm. Cmpliance Services will respnd t all student inquires via within ne business day. Entering Immunizatin Recrds n the Cmpliance Services Management System Each student is respnsible accessing the Cmpliance Services Management System t accurately enter their immunizatin histry nt their Immunizatin Recrd. Students must enter individual dates fr each vaccinatin required by their institutin. It is highly recmmended that students enter all nn-required vaccinatins nt their recrd, such as HPV vaccines, Flu vaccines, r ther immunizatins nt required by their institutin. Uplading Immunizatin Dcuments Dcuments that are upladed directly must be in ne f the fllwing frmats:.gif,.png,.tiff,.tif,.jpg,.jpeg,.txt, r.pdf.

6 Micrsft Wrd files such as.dc,.dcx, r.dcm frmats are nt accepted. Please make sure that yur file name cnsists f nly alpha and numeric characters in the file name. NO SPECIAL CHARACTERS OR EXTRA SPACES ARE ALLOWED. Examples f ACCEPTABLE file names: JaneSmithRecrds.jpg bmp Examples f UNACCEPTABLE file names: Jane Smith Recrds. Jpg (Unacceptable due t spaces between wrds) ImRecrd#1.bmp (Unacceptable due t special character # ) What t Expect After Submissin Upladed dcuments are available immediately fr review by MCS Staff. It typically takes 5 business days t prcess immunizatin recrds. Once recrds have been successfully reviewed and matched, students will be ntified by . Checking yur Status Once lgged int the Cmpliance Services Management System, select View Histry and yu can view yur status.

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