Pertussis and Flu Vaccination
Your school is offering Tdap (pertussis or “whooping cough” vaccine) and Flu vaccine to students, staff, parents, and siblings. Please fill out a registration form for each family member you wish to be vaccinated. Please read through the Notice of Privacy Practices. Then, print, sign and return the NPP Acknowledgment Form.
Beginning Fall 2012, Illinois law will require all students entering 6th and 9th grades to provide proof of Tdap immunization in order to remain in school. Tdap shots administered in Spring 2011 will fulfill this requirement. For more information on this new requirement, please click here.
- Complete the Parental Release Form for each student or child you wish to be immunized (Siblings are welcome!). You may type in the form, print, and sign.
- Complete an Adult Vaccination Form for each parent or adult you wish to be immunized (Family members are welcome!). You may type in the form, print, and sign.
- You may either scan the signed forms and email them as PDF or JPEG attachments to immunizations@uchospitals.edu or fax them to 773.753.8230, Attention: Heather Limper.
- Please understand your benefits and insurance coverage. It is your responsibility as a patient to know what services are covered by your insurance plan and what additional fees will be owed.
Notice of Privacy Practices
NPP Acknowledgement Form
Student Vaccination Form
Adult Vaccination Form
Note: The University of Chicago will enter your immunization information into a statewide registry called Illinois Comprehensive Automated Immunization Registry Exchange (ICARE). This service allows providers across the state to access your immunization record when necessary and ensures this information is kept in a secure place accessible to your healthcare providers. If you wish to opt-out of this service, please indicate that either on your consent form or via email/ fax.
