Immunization Lang Wellness Center Health

Immunization Form

Lang Wellness Center
Rockford University and the state of Illinois require anyone taking six or more credit hours to submit up to date immunizations. This HIPAA compliant form can be used to submit your immunizations.

Due date for students starting in the Fall Semester:

September 1

Due date for students starting in the Spring Semester:

February 1

Failure to provide the required documentation by the due date will result in a registration hold. You will be notified through your Rockford University email if any documentation or information is incomplete.
Full Name*

First NameMiddle NameLast Name
Rockford University ID Number
e.g., 123456
Year and Semester Entering RU*
Date of Birth*

MonthDayYear
Date
Gender*
Citizenship*

USOther
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rockford University Email*
example@Rockford.edu
Student Phone Number*

Area CodePhone Number
Have you previously attended Rockford University?*

YesNo
If you answered yes to the above question, when did you attend? *
Did you transfer to Rockford University?*

YesNo

To obtain your immunization records, contact your high school, previous university or college, military, public health department, or your health care provider. Records may be uploaded below or faxed to 815-226-3335.
STUDENT IMMUNIZATION REQUIREMENTS
The Illinois Department of Public Health College Immunization code (77 ill. adm.Code 694) requirements for all students taking 6 or more credit hours are:
- Three (3) vaccines that contain Tetanus/Diphtheria/Pertussis, one of which must be a Tdap vaccine. The last dose of vaccine must be within ten years. Vaccines must be at appropriate intervals (#1 and #2 at least 28 days apart, #3 no less than 6 months after #2). Tetanus Toxoid (TT, or Tetanus) is not acceptable.
- Two (2) Measles, Mumps, Rubella (MMR) vaccines administered after the first birthday and at least 28 days apart. Students who are unable to provide proof of vaccinations may provide serologic evidence (IGG antibody titres) of measles, mumps, rubella. Please attach lab report.
- Newly admitted students under the age of 22 are required to show proof of One (1)meningococcal conjugate vaccine administered on or after the age of 16. Non conjugate vaccinations are not acceptable. The Illinois Department of Public Health has made a meningococcal disease brochure available for college students and their parents.
Meningococcal Disease Brochure:What Parents and Students Need to Know

*Rockford University will be following the CDC guidelines along with our local health department's recommendations for COVID-19.
Please Upload your Immunization Records*

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Lang Wellness Center

5050 East State Street

Rockford, IL 61108

phone: 815-226-4083 fax:815-226-3335

HealthCenter@Rockford.edu
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Immunization Form

STUDENT IMMUNIZATION REQUIREMENTS