IMMUNIZATION HISTORY STUDENT’S NAME:_____________________________
IF YOUR BIRTH DATE IS BEFORE JANUARY 1, 1957, PLEASE CONTACT HEALTH SERVICES AT 309-677-2700.
SECTION 1: TUBERCULOSIS (TB) SCREENING REQUIRED BY BRADLEY UNIVERSITY
CHECK ANY THAT APPLY:
_____ FROM OR HAVE LIVED FOR TWO MONTHS OR MORE IN ASIA, AFRICA, CENTRAL, OR SOUTH AMERICA OR
EASTERN EUROPE
IF YES, WHICH COUNTRY:____________________________________________________
_____ HAVE BEEN DIAGNOSED WITH A CHRONIC MEDICAL CONDITION THAT MAY IMPAIR YOUR IMMUNE SYSTEM
IF YES, WHAT CONDITION:____________________________________________________
_____ A HEALTH CARE WORKER
_____ A VOLUNTEER OR EMPLOYEE OF A NURSING HOME, PRISON, OR OTHER RESIDENTIAL INSITUTION
_____ CONTACT WITH A PERSON KNOWN TO HAVE ACTIVE TUBERCULOSIS
_____ NONE OF THE ABOVE APPLY
IF ANY OF THE ABOVE DO APPLY, TB SCREENING IS REQUIRED. OPTIONS ARE AS FOLLOWS:
1.) SCHEDULE AN APPOINTMENT AT STUDENT HEALTH FOR PPD SCREENING TEST
2.) PROVIDE DOCUMENTATION OF NEGATIVE TB SKIN TEST DONE IN THE UNITED STATES WITHIN THE LAST 12
MONTHS PPD TEST DATE ____/____/____ DATE READ ____/____/____
MILLIMETERS INDURATED_____MM POS_____ NEG_____
3.) PROVIDE DOCUMENTATION OF PRIOR TREATMENT OF ACTIVE TB DISEASE
SECTION 2: REQUIRED VACCINATIONS
PLEASE ATTACH A COPY OF YOUR IMMUNIZATION RECORDS VERIFIED BY A PHYSICIAN. THE STATE OF ILLINOIS
REQUIRES THE FOLLOWING IMMUNIZATIONS FOR STUDENTS AT HIGHER EDUCATION INSTITUTIONS:
1) DIPHTHERIA, TETANUS, AND PERTUSSIS
STUDENTS SHALL PROVIDE DATES OF ANY COMBINATION OF THREE OR MORE DOSES OF DIPHTHERIA,
TETANUS, AND PERTUSSIS CONTAINING VACCINE. ABBREVIATIONS FOR THESE VACCINES INCLUDE DTP,
DTAP, DT, TD, OR TDAP. ONE DOSE MUST BE A TDAP. THE LAST DOSE MUST HAVE BEEN RECEIVED WITHIN
10 YEARS PRIOR TO ENROLLMENT.
2) MEASLES, MUMPS, AND RUBELLA
STUDENTS SHALL PROVIDE DOCUMENTATION OF RECEIPT OF TWO DOSES OF MEASLES, MUMPS, AND
RUBELLA (MMR) VACCINE. THE FIRST DOSE MUST HAVE BEEN RECEIVED ON OR AFTER THEIR FIRST
BIRTHDAY.
3) MENINGITIS
ALL NEW ADMISSIONS UNDER THE AGE OF 22 SHALL PROVIDE DOCUMENTATION OF HAVING AT LEAST ONE
DOSE OF MENINGOCOCCAL VACCINE ON OR AFTER 16 YEARS OF AGE. THE NEW MENINGITIS B VACCINE
DOES NOT FULFILL THIS REQUIREMENT.
A STUDENT MAY BE EXEMPTED BY THE HEALTH CENTER IF A WRITTEN STATEMENT FROM THE STUDENT (OR GUARDIAN, IF
THE STUDENT IS A MINOR) DETAILING OBJECTION TO IMMUNIZATION ON GROUNDS THAT THEY CONFLICT WITH TENETS OR
PRACTICES. GENERAL PHILOSOPHICAL OR MORAL OBJECTION TO IMMUNIZATION SHALL NOT BE SUFFICIENT FOR AN
EXEMPTION ON RELIGIOUS GROUNDS.