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Personal information forms

• The Request for Special Accommodations Form is due by June 26 for housing accommodations and by July 15 for classroom accommodations. All students requiring academic, housing or other accommodations should use this form.

• The Immunization Form is due by July 1. It is required for all incoming students.

Important note:

Before filling out the Immunization Form online, you will need to print an Immunization Record for your physician to complete and sign.

The completed Immunization Record must be attached to the Immunization Form where indicated.

If you cannot attach the form:

U.S. citizens may fax it to 309-794-8528 or mail it to Dean of Students Office, Augustana College, 639 38th St., Rock Island, Ill., 61201.

Non-U.S. citizens may fax it to 309-794-7445 or mail it to International Student Life, Augustana College, 639 38th St., Rock Island, Ill., 61201.

For assistance with either of these forms, email or call the Dean of Students Office, 309-794-7502.

Immunization requirements

• The State of Illinois and Augustana College require proof of immunity to certain vaccine-preventable diseases.

• Students who are not in complete compliance with the requirements by the 10th day of classes in fall term will be restricted from registering for winter term classes.

• People born before Jan. 1, 1957, are exempt from the MMR vaccine requirements only. The Tdap is required.

• Non-U.S. citizens of all ages are required to provide documentation of a tuberculosis test and the test results. If tested positive for tuberculosis, a chest X-ray and X-ray  results also are required.

All immunizations records must be completed as follows:

1. All dates must be certified by a physician, public health official, or a registered nurse.

2. All dates in a series of immunizations must be included.

3. All dates must include at least month and year; month, date and year for measles, mumps and rubella.

4. Information must be in English or accompanied by an official translation.

5. Proof of all the following must be provided: Tdap (adult dose of tetanus, diptheria, acellular pertussis within the last 10 years.)

Primary immunizations of three doses at 4-8 week intervals beginning when 6-8 weeks old; a fourth dose given one year after the third dose. A fifth dose given prior to school entry unless the fourth dose was given after the fourth birthday.

Tdap (tetanus/diphtheria/pertussis)

1. The minimum time interval between the first and second dose must be at least one (1) month or more with a minimum of six (6) months between the second and third dose.

2. Receipt of Tetanus Toxoid (T.T.) vaccine is not acceptable in fulfilling this requirement.

3. Non-U.S. citizens of all ages required to provide documentation of three (3) doses of tetanus/diphtheria/Tdap with the last dose of being the Tdap (adult dose of tetanus, diphtheria, acellular pertussis)

Measles (rubeola, 10 day, red, hard)

1. Two (2) doses at least one month apart of live measles vaccine after Jan. 1, 1969, and on or after 12 months of age; MMR is preferred if a second dose is needed prior to college attendance; OR non-U.S. citizens of all ages must have one dose at least one month prior to attending.

2. Date disease diagnosed and certified by a physician OR lab test proving high immunity (lab report must be attached to the immunization form).

Mumps (Two doses at least one month apart of live mumps vaccine)

1. Live virus vaccine given after 12 months of age and after Jan. 1, 1968 OR non-U.S. citizens of all ages must have one dose at least one month prior to attendance.

2. Date disease diagnosed and certified by a physician OR lab test proving high immunity (lab report must be attached to the immunization form).

3. ELISHA or RHA lab test proving immunity (lab report must be attached to the immunization form).

Rubella (German measles, 3 day) – history of disease is not acceptable.

1. Live virus vaccine given after 12 months of age and after June 1, 1969, OR non-U.S. citizen of all ages must have one dose at least one month prior to attendance.

2. Lab test proving high immunity (lab report must be attached to the immunization form).

MMR – 2 doses after May 1, 1971 and after 12 months of age.

Tuberculosis (non-U.S. residents only)

1. Tuberculin Skin Test, date given, result.

2. Chest X-ray if required, date given, result.

Exemptions

Only the following exemptions will be accepted and statements must accompany this record. Statements must be on official letterhead and in English.

Medical contraindications — A written, signed and dated statement from a physician stating the specific vaccine(s) contraindicated and duration of 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 under the age of 18) describing his/her objection to immunization based upon recognized religious tenets and practice.

Pregnancy or suspected pregnancy – A signed statement from a physician stating the student is pregnant or pregnancy is suspected.

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

Individuals born before Jan. 1, 1957, wishing to be exempted from the immunization requirement must provide evidence of their birth date by submitting either a copy of their birth certificate, driver's license or personal identification card issued by the secretary of state.