DIPHTHERIA (DTaP / TDaP / TD) TETANUS Lockjaw 招商经理PERTUSSIS Whooping Cough 白喉（DTaP疫苗/ TDAP/ TD） 破伤风 百日咳 Given within 10 years of attendance & every 10 years as adult, not less than 28 days apart. International Students are required to provide dates of 3 or more dos. Tetanus Toxoid (TT ) is not acceptable evidence of immunity. | 1st Shot Date第一次注射时间 (check one) ❑DTaP ❑TDaP ❑TD___ ____/____/_______ 10年以内的出勤率【估计是指10岁以内的接种情况】 成人每10年接种一次的情况， 接种间隔时间不少于28天。 国际留学生要求提供3次及以上给药的日期。 破伤风类毒素（TT）不能作为免疫力的证据。 | 2nd Shot Date (check one) ❑DTaP ❑TDaP ❑TD___ ____/____/______ 【我国7岁以前总共接种5次百白破混合制剂的疫苗，14岁以后是每10年接种一次】 | 3rd Shot Date (check one) ❑DTaP ❑TDaP ❑TD___ ____/____/______ | 4th Shot Date (check one, if applicable) ❑DTaP ❑TDaP ❑TD___ ____/____/______ |
MEASLES Rubeola OR (MMR) 麻疹风疹或MMR 2 dos required, at least 28 days apart, after 12 months of age, given in 1968 or later. | 1st Shot Date ____/____/_______ 要求2次给药，至少28天间隔，1岁以后【我国好像是8个月后就可以打了】，1968年或以后给药的。 | 2nd Shot Date ____/____/______ | ❑OR diagnosis date 或诊断时间 ____/____/______ | ❑OR positive blood titer with REQUIRED copy of lab report. 或阳性的血液 滴度，附有必须 的实验室报告 |
MUMPS OR (MMR) 流行性腮腺炎或(MMR，麻疹、腮腺炎和风疹的混合疫苗) 2 dos required, after 12 months of age. | 1st Shot Date ____/____/_______ | 2nd Shot Date ____/____/______ | ❑OR diagnosis date 北京红酒____/____/______ | ❑OR positive blood titer with REQUIRED copy of lab report. |
RUBELLA German Measles OR (MMR) 德国麻疹或风疹(MMR) 1 do required, after 12 months of age. | 1st Shot Date ____/____/_______ | 2nd Shot Date ____/____/______ | A history of Rubella is not acceptable evidence of immunity. | ❑OR positive blood titer with REQUIRED copy of lab report. |
TUBERCULOSIS (TB) 我爱世界杯结核 Screening via PPD (Purified Protein Derivative) or QuantiFERON® -TB Gold, required for International Students. | Tuberculin Test Given ❑QuantiFERON® ❑PPD skin test__ ____/____/_______ 对国际留学生，要求通过PPD（纯蛋白衍生物）或者QuantiFERON® -TB Gold（QFT-G）实验进行筛选。 | Test Read Date ____/____/______ | Result (level OR mm) _____ level _____ mm | Interpretation ❑Positive ❑Negative |
Tuberculin Results / Chest X-Ray 结核菌素结果/胸部X光 Report required as attachment if tuberculin test is interpreted as positive. Results must be within the last 12 months, indicating actual mm of induration, (transver diameter of zero if no induration) or level. 如果结核菌素实验阳性的话，报告要求附上。结果必须是最近12个月以内的，提供了硬结确切的大小（单位为毫米）【平均直径】（如果无硬结的话，横向直径为零），或者级别【估计是指阴性，弱阳性，阳性，强阳性】。 | Return completed form to: IIT Student Health & Wellness Center 10 W. 35th Street, IIT Tower Suite 3D9 – 1 Chicago, IL 60616 Phone 312-567-7550 Fax 312-567-5702 Email student.health@iit.edu Web www.iit.edu/student_health/ |
Physician or public health official verification - I verify to the best of my knowledge that the above immunization information is correct. |
Physician Name (clinic stamp or al REQUIRED): | Date (mm/dd/yyyy) ______/______/___________ |
Physician’s Signature: |
This form must be completed and returned with applicable attachments before the student is allowed to register. |
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