This Certificate of Immunity Form must be completed and returned prior to the student's first enrollment.

NOTE: Illinois law requires incoming new students to document immunity to tetanus/diphtheria, measles, rubella and mumps.

The following rules will apply:

1. All dates must include Month, Day and Year - if it can not otherwise be determined that the specific vaccine(s) was administered at the minimally acceptable age or dosage interval.


2. Part II: Proof of immunity may be provided by a copy of the student's Certificate of Child Health Examination from your school (high school or college) or your doctor which provides the complete information necessary to assure compliance with the Act. The Certificate of Child Health Examination must be reviewed for compliance and attached to this form. Part III need not be completed.


3. Part III: must be completed and signed by a health care provider*.
   
   • All laboratory evidence of immunity must be accompanied by a copy of the laboratory report.
   • History of rubella disease is not acceptable as proof of immunity.
   • All live virus vaccines must have been given on or after the first birthday.
   • Mumps titer is only acceptable as proof of immunity if the laboratory test used was a neutralization, enzyme-linked immunosorbent assay (ELISA or EIA) or radical hemolysis antibody test. A four-fold rise in antibody titer between appropriately spaced acute and convalescent sera is also acceptable.


4. Only the following exemptions will be accepted and statements must accompany this record:
   
   • Medical Contraindications - A written, signed and dated statement from a physician stating the specific vaccine or vaccines contraindicated and duration or medical condition that contraindicates the vaccine(s).
   • Religious Exemption - A written, signed and dated statement by the student (or parent/guardian if the student is a minor) describing his/her objection to immunization on the grounds that they conflict with the tenet and practices of a recognized church or religious organization, of which the student is an adherent or member.
   • Pregnancy or Suspected Pregnancy - A signed statement from a physician stating the student is pregnant or pregnancy is suspected.


5. Anyone with a vaccine exemption may be excluded from the college/university in the event of a measles, rubella, mumps or diphtheria outbreak in accordance with public health recommendations.


6. All records not in English must be accompanied by a certified translation.