Student Health Services
Health Information Management
Campus Box 2540
Normal, IL 61790-2540
Telephone: (309) 438-7559
FAX: (309) 438-5205
Welcome to Illinois State University!
On behalf of Student Health Services, we look forward to serving you. We invite you to visit our Web site at
www.shs.ilstu.edu to learn about the medical care and the health insurance services available at Illinois State University.
Please complete the immunization information below. The signed form must be returned to Student Health Services
before the 15th calendar day of your first term. Fax the records to 309-438-5205 or bring them in person to Student
Health Services.
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All dates must be certified by a health care provider
All dates in a series must be included
All dates must include the month, day, and year
All information must be in English
Requirements
Td (tetanus/diphtheria)
International Students are required to provide dates of any combination of three or more doses of Diphtheria,
Pertussis, and Tetanus(DPT), Tetanus and Diphtheria (Td), or Tetanus, Diphtheria, and Acellular Pertussis (Tdap)
vaccine, with the most recent dose having been received within 10 years of the first term of enrollment.
Measles (rubeola, 10 day, red, hard)
All students must have two injections, at least 30 days apart, of live measles vaccine after 12/31/68 and after 12
months of age, or have their physician write the date the disease was diagnosed, or provide a laboratory report
proving immunity.
Mumps
All students must have a live virus injection after 12 months of age, or have their physician write the date the
disease was diagnosed, or provide a laboratory report proving immunity.
Rubella (German measles, 3 day)
All students must have a live virus injection after 12 months of age or provide a laboratory report proving
immunity.
Tuberculosis screening
International students are required by University regulations to have TB screening within ten days of their arrival on
campus. Student Health Services Preventive Medicine appointments may be scheduled by calling (309) 438-2778.
If you have questions, please call 309-438-7559.
Sincerely,
Patient Support Services
Name:
Date of Birth:
University ID Number (UID):
Health Care Provider Record of Immunization: Enter Month, Day, and Year.
DIPHTHERIA - PERTUSSIS - TETANUS (DPT OR baby shots)
1
2
TETANUS - DIPHTHERIA (Td - within 10 yrs. of attendance; every 10 yrs as adult)
1
2
Td requirement is met by Tdap,
 Adacel or  Boostrix
MMR
MEASLES (hard, red, 10 day) - 2 doses after 12 months and after 12/31/68
MUMPS - after 12 months and after 12/31/67
RUBELLA (3 day, German) - after 12 months and after 12/31/68
3
4
1
2
1
2
1
 OR date disease
diagnosed by doctor
 OR BLOOD TITER - copy
of lab report MUST be
attached.
 History of Rubella not
acceptable.
1
1
HEALTH CARE PROVIDER OR PUBLIC HEALTH OFFICIAL VERIFICATION: I verify to the best of my knowledge that the above immunization/TB test
information is correct.
Physician Name (print or stamp)
Signature
Date
Address
Phone
DO NOT WRITE IN SHADED AREA - FOR ISU STUDENT HEALTH SERVICE USE ONLY
Patient Label
Immunizations reviewed & documented in EHR by
Complete
Received by
Incomplete
Mail
FAX
Reception
Date
Accredited by Accreditation Association for Ambulatory Health Care, Inc.
Date
PM
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Other
Appt.