Health Services- University of Illinois at Springfield

Text Box: Born Before
Jan 1st 1957

Diamond: *2 Mumps See Below Diamond: *2 Measles See Below Oval: No

Diamond: *1 Rubella See Below

Oval: Yes

ARE YOU IN COMPLIANCE ??

Oval: Yes

*Doses must be on or after 1st birthday & they must be after 6/10/1969 and at least 30 days apart or may provider copy of lab test providing immunity.

** Doses must be on or after 1st birthday & they must be after 5/1/1971 and at least 30 days apart.

Text Box: **2 MMR's See Below Oval: Yes Oval: No

Text Box: Are you a US Citizen Text Box: Not In Compliance

Text Box: 1 Tetanus Diphtheria in Last 10 yrs Oval: Yes

Oval: No

Text Box: Tuberculosis test done in USA at a Public Health or University Clinic - No sooner than 60 days prior to registration Text Box: Not In Compliance Oval: No Diamond: 3rd TD in Last 10 yrs Diamond: 2 Tetanus Diphtheria