Admission Health Record Packet
Complete and return:
This packet includes:
- Medical Record Identification (emergency contact, medical release) completed by student
- Personal Health History completed by student
- Physical Examcompleted by healthcare provider
- This is an opportunity to see a healthcare provider, review the tuberculosis screening form, and receive any required or recommended immunizations.
- Tuberculosis Screening Questionnaire completed by student and reviewed by healthcare provider
- Tuberculosis Screening Risk Assessment (if questionnaire positive) completed by healthcare provider
- Certificate of Immunity completed by student and verified/signed by healthcare provider
Completed Admission Health Record Packets are due:
- July 1, for students admitted for Fall 2018
- December 20, for students admitted for Spring 2019
Return your completed packet to firstname.lastname@example.org or mail to:
116 S. Michigan Ave., 13th floor
Chicago, Illinois 60603
Immunization Requirement Information
In accordance with the Illinois College Student Immunization Act, all students who enroll in 6 or more credit hours per semester must prove that they have been immunized against the following communicable diseases:
Measles (Rubeola): Students must provide documentation of receipt of two doses of live measles virus vaccine on or after the first birthday. The minimum time interval between each dose must have been at least 28 days. If either dose was given before 1968, proof must be provided that a live virus was administered. Students who cannot obtain records may provide laboratory (serologic) evidence of measles immunity*.
Mumps: Students must provide documentation of receipt of two doses of live mumps virus vaccine on or after the first birthday. The minimum time interval between each dose must have been at least 28 days. If either dose was given before 1968, proof must be provided that a live virus was administered. Students who cannot obtain records may provide laboratory (serologic) evidence of mumps immunity*.
Rubella (German Measles): Students must provide documentation of receipt of two doses of live rubella virus vaccine on or after the first birthday. The minimum time interval between each dose must have been at least 28 days. If either dose was given before 1968, proof must be provided that a live virus was administered. Students who cannot obtain records may provide laboratory (serologic) evidence of rubella immunity*.
Diphtheria/Tetanus/Pertussis: Students must provide dates of any combination of three or more doses of Diphtheria, Tetanus, and Pertussis containing vaccine. One dose must be the Tdap vaccine. The last dose of vaccine (DTP, DtaP, DT, Td, or Tdap) must have been received within the last 10 years. The minimum time interval between the first and second dose must have been at least 28 days, with the third dose having been received at least six months after the second or last dose of the basic series.
Meningococcal Conjugate Vaccine: All new admissions under the age of 22 must show proof of having at least one dose of meningococcal conjugate (Menactra®, Menveo®, and MenHibrix®) vaccine on or after 16 years of age.
*A serology report is a blood test you can have done by your healthcare provider to test for positive antibodies which prove immunity. Lab results must be attached.
Exemptions that will be accepted:
- Medical Exemption: Students who have a medical reason that contraindicates vaccination should ask their healthcare provider to complete the
- Religious Exemption: Students who have a religious objection to immunization should complete the
- Pregnancy or Suspected Pregnancy: Students who are pregnant or suspected to be pregnant should ask their healthcare provider to complete the Medical Immunization Exemption Form.
Anyone with a vaccine exemption may be excluded from the College in the event of a disease outbreak in accordance with public health law.
Please note: if you were born on or before January 1, 1957, you are exempt from the measles, mumps and rubella requirements, as exposure to disease and natural immunity is assumed. You will however, need to show proof of immunity to diphtheria, tetanus, and pertussis.
Proof of Immunity
Proof of immunization, a certificate of medical exemption to immunization, or a statement of religious objection to immunization must be on file with SAIC Health Services prior to registering for class. Students who do not have one of these three documents on file with Health Services by the beginning of preregistration will have a registration hold placed on their academic record and will not be permitted to register for the following semester.
Students can submit proof of current immune status to the above diseases by attaching relevant records from a high school, prior college, military, government, clinic or hospital or by having the SAIC Certificate of Immunity below completed and signed by a health care provider. Documents must be in English. Please send copies and retain original documents for your own records.
IMPORTANT: You will be notified at your SAIC email account if we receive incomplete records. This email address will be used for future communications from Health Services as well.
Recommended (not required) vaccines for college students:
- Hepatitis B is a serious infectious disease that attacks the liver and can lead to lifelong infection, liver failure, and even death. The following factors can increase the risk of contracting Hepatitis B: unprotected sex, non-sterile body piercing, tattoos, sharing needles, and travel abroad to countries with high rates of hepatitis B.
- Varicella (Chickenpox) is a very contagious virus causing a rash, fatigue and fever. While the symptoms are usually mild in children, college students may be more likely to develop serious complications.
- HPV (Human Papilloma Virus) is a group of viruses that can cause genital warts and cancers of the cervix, vulva, vagina, penis, anus, mouth or throat.