Medical Student Immunizatin Requirements The State f Illinis cde, Reference: (110 ILCS 20) Cllege Student Immunizatin Act, requires students t prvide prf f immunity: Measles (Rubela), Mumps, Rubella (German Measles); Tetanus/ Diphtheria/Pertussis and Meningcccal. T help in meeting this requirement, entering students may get their immunizatins at the Student Health Service SHS. Students must uplad Immunizatin frms int the Cmpliance Management System. The link t this prtal can be fund at http://wellness.uchicag.edu/page/vaccinatinsrequired-enrllment. Failure t return yur immunizatin frm will result in yur being placed n restrictin, which will deny yu the ability t enrll in future classes. Questins? Call (773) 795-0013 during business hurs. Please indicate that yu are an incming medical student. Entering medical students are required t prvide: Prf f immunity thrugh bld titer t Measles (Rubela), Mumps, German Measles (Rubella), and Hepatitis B. Prf f immunity thrugh bld titer r vaccinatin t Varicella. Current Tetanus/Diphtheria/Pertussis vaccine. Prf f Meningitis vaccine if under 22 years f age Tuberculsis screening Imprtant infrmatin: A licensed healthcare prvider must cmplete the immunizatin frm. A health care prvider is: a physician licensed t practice (M.D. r D.O.), a Licensed Nurse, r a Public Health Official. 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. EXEMPTIONS: The fllwing exemptins may be allwed. Anyne with a vaccine exemptin may be excluded frm the University/Cllege in the event f a Measles, Mumps, Rubella r Diphtheria utbreak in accrdance with public health law. MEDICAL CONTRAINDICATIONS: 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 SHCS sccimm@uchspitals.edu Student Health Service Immunizatin Prgram. PREGNANCY 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 sccimm@uchspitals.edu the SHCS Student Health Service Immunizatin Prgram. AGE EXEMPTION: Persns brn befre January 1, 1957 are cnsidered immune t Measles, Mumps, and Rubella. Requirements may be met by the submissin f a cpy f the student's birth certificate, driver's license, r passprt identifying the birth date. RELIGIOUS EXEMPTION: 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. Rev 02/22/17
Frequently Asked Questins Medical Student Immunizatin Recrd Q: Can I just submit cpies f my vaccines instead f cmpleting the Immunizatin Recrd? A: The Immunizatin Recrd is a required dcument. Please make certain that yu submit the frm specifically fr Medical Students. This frm must be cmpleted and signed by a licensed healthcare prvider. Q: Why isn t my immunizatin histry sufficient fr prf f immunity? A: The University f Chicag adheres t the guidelines f the American Assciatin f Medical Clleges (AAMC) and, the Center fr Disease Cntrl (CDC) and Preventin fr healthcare wrkers and the requirements f the State f Illinis. Prf f immunity must be verified via bld titers fr Measles, Mumps, Rubella, Varicella and Hepatitis B. Immunity fr Tetanus and Pertussis are verifiable by a 3 dses f Diphtheria/Tetanus/Pertussis (Tdap) vaccine. Q: If I need bld titers, why shuld I submit my immunizatin histry? A: Immunizatin dates are imprtant in the event that yur bld titers are negative. Each required titer has a specific number f dses needed t cmplete a series. Fr example, Illinis requires the fllwing: either tw dses f MMR. It is als imprtant t nte that the first dse f MMR is nt given befre 12 mnths f age (yur first birthday). If a titer is negative fr any f the required immunizatins, specific guidelines are available fr attempting t bst ne s immunity. In mst cases, an additinal dse f the vaccine will be administered and the titer rechecked after 30 days, if it is nt medically cntraindicated. Q: What if I had the Varicella infectin (chickenpx) as a child? A: In mst cases, yur titer will prve immunity if yu had the infectin in the past. Otherwise yu will be required t cmplete a tw dse series fr Varicella. Q: I started the Hepatitis B series but never cmpleted it. D I need t start the series ver? A: Generally, we dn t restart the series. The mst cmmn apprach wuld be t give the missing dse, wait 30 days, then have a Hepatitis B Surface Antibdy rechecked. Q: I had a PPD (TB skin test) last year. D I need anther ne? A: Tuberculsis testing must be perfrmed within three mnths f rientatin date. This is a tw step prcess. The secnd PPD will be placed during rientatin. Q: What if I have had a psitive PPD in the past? A: If yu have had a psitive reactin, yur healthcare prvider must prvide dcumentatin f the reactin size, fllwed by a Chest X-ray r Quantifern Gld/T-spt testing. Any reactin greater than 10mm requires additinal testing fr healthcare wrkers. Please attach a cpy f the Chest X-ray r Quantifern Gld/T-spt testing results t yur health frm. Als nte that receiving the BCG vaccine des nt always present a psitive reactin. Therefre, a Chest X-ray r Quantifern Gld/T-spt testing is necessary fr a psitive PPD reactin. Q: Why des the University f Chicag require s much prf f immunizatin? A: All medical clleges require the same. It is ur intent t maintain healthcare and prvide knwledge f cmmunicable diseases within the prfessin yu have chsen. It is imprtant in healthcare t KNOW YOUR STATUS. Have any ther questins? Email Keeya.Bailey@uchspitals.edu Rev 02/22/17
Medical Student Immunizatin Recrd Student ID# Quarter Attending Calendar Year Part I: Student Infrmatin Last Name: First Name: Middle Name: Date f Birth (mm/dd/yyyy): Gender: Preferred Telephne Number: E- mail: Part II: Prf f Immunity Part II is t be cmpleted and signed by health care prvider(s). A health care prvider is a physician licensed t practice medicine in all f its branches (MD r DO), a Licensed Nurse, r a Public Health Official. MEASLES (Rubela) Date f bld titer: / / (mm/dd/yyyy) RUBELLA (German Measles) Date f bld titer: / / (mm/dd/yyyy) MUMPS Date f bld titer: / / (mm/dd/yyyy) MMR Vaccine MMR #1 Date f Vaccine / / (must be given n r after 12 mnths f age) MMR #2 MMR #1) Date f Vaccine / / (must be given at least 28 days after - - If individual vaccines were received fr Measles, Mumps, and Rubella, please cmplete the fllwing: Measles (Rubela) Vaccine Rubella (German Measles) Vaccine Mumps Vaccine Rev 2/14/17jc Page 3 Date f Vaccine # 2 / / Date f Vaccine # 2 / /
Student ID# Quarter Attending Calendar Year HEPATITIS B (Bth Step 1 and Step 2 are required.) Step 1. Vaccine Series (must be started befre entry t schl) Date f Vaccine # 1 / (mm/dd/yyyy) Vaccine # 2 / / (mm/dd/yyyy) Vaccine # 3 / / (mm/dd/yyyy) * Vaccine schedule as apprved by the CDC: Three ttal dses given at 0, 1-2, and 4-6 mnths. Step 2. Prf f Immunity (may be cmpleted during first quarter f schl) Date f Antibdy bld titer: / / (mm/dd/yyyy) Nte: Antigen test nt accepted; must be Antibdy) VARICEL LA ZOSTER / CHICKE N POX TETANUS/ DIPHTHERIA/ PERTUSSIS Date f bld titer: / / (mm/dd/yyyy) Dates f immunizatin if yu have nt had chicken px: (Tw dses separated by at least 30 days are required) Date f Vaccine # 1 / / (mm/dd/yyyy) Date f Vaccine # 2 / / (mm/dd/yyyy) All students must shw prf f vaccinatin f three (3) dse f 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 first date f Quarter Tetanus Txid vaccine is nt acceptable in fulfilling this requirement Date f Vaccine # 1 / / (mm/dd/yyyy) DPT,DTP,DT,DTap, Td r Tdap Date f Vaccine # 2 / / (mm/dd/yyyy) DPT,DTP,DT,DTap, Td r Tdap Date f Vaccine # 3 / / (mm/dd/yyyy) DPT,DTP,DT,DTap, Td r Tdap MENINGOCOCCAL VACCINE (MENACTRA MCV4, MENOMUNE MPSV4, MENVEO MENINGOCOCCAL Required fr all new students under the age f 22 One dse must have been given n r after 16 th birthday Date f Vaccine / / Rev 2/14/17jc Page 4
Student ID# Quarter Attending Calendar Year Part III: Tuberculsis Screening Tuberculin skin test (Mantux nly) (t be cmpleted within 3 mnths f entry) Or Date f placement: / / (mm/dd/yyyy) Date read: / / (mm/dd/yyyy) mm induratin (If n induratin, recrd 0.) Chest X-ray, if the student has a histry f a psitive TB skin test r treated TB disease (must be dne in the USA within 1 year f registratin) Date f Chest X-ray: / / (mm/dd/yyyy) (must attach chest X-ray reprt) Date f Quantifern Gld/T-Spt test: / / (mm/dd/yyyy) Part IV: Health Care Prvider Certificatin Prvider(s) Signature: Prvider(s) Printed Name(s): Address: Phne Number: OFFICE USE ONLY Immune Exempt Outstanding Reviewed by: Measles G. Measles Mumps Tet/Dip Hepatitis Varicella Date: Rev 2/14/17jc Page 5