出国免疫接种情况表中文翻译.docx

I un dersta nd that,complia nce audits or in the event of a health or safety emerge ncy. All imm uni zati on docume nts submitted to IIT become the property of the Uni versity. I un dersta nd that, uni ess required to do so by law, IIT will not re-release my imm uni zati on records to any third party. 我授权伊利诺理工大学来发布这份免疫记录给伊利诺斯州卫生部门，或者它指定的符合性审计的代表, 或者一个健康的事件，或安全相关的紧急情况。 Please complete either Option A or Option B (choose one) 请完成选项A或者B (二选一)。 Option A : Attach a copy of your Official Immunization records proving ALL immunizations are current. Skip Option B. 提供一份你的官方的免疫记录的副本，以证明现有的所有的免疫注射情况。 Option B : See below - Remainder of form to be completed and signed by physician or health care provider. Option B: To be completed and signed by physician or health care provider. Please note the following: 由(内科)医生或卫生保健提供者完成。请注意一下几点 ? Positive laboratory (serologic) evidence of immunity via blood 通过查血(得知)的免疫力的阳性的实验室(血清学)证据 (antibody) titer is acceptable proof for Measles, Mumps and Rubella. 对于麻疹，腮腺炎和风疹，抗体滴度是可接受的证明。 ? Include all lab evidence with copy of lab report. 包括了所有的能提供实验室报告副本的实验室证据。 ? All documents must be in English or accompanied by a certified translation. Exemptions: The following exemptions will be accepted with official supporting documentation. 例外情况： ? Medical / Pregn ancy Exemptions 医学或妊娠的例外情况 ? Religious Exemptions 宗教豁免权 ? Anyone with an exemption may be excluded from campus in the event of a health emergency, in accordance with public health law. 根据公共卫生法，在进入卫生紧急状态的情况下，有豁免权的任何人可能从 被排除在校园之外。 所有文件必须是英文的，或者附有一份认证的翻译。 DIPHTHERIA (DTaP / 1st Shot Date第一次注射时间 2nd Shot Date 3rd Shot Date 4th Shot Date TDaP/TD) (check one) (check one) (check one) (check on e, if applic TETANUS Lockjaw DTaP DTaP DTaP DTaP PERTUSSIS Whoopi ng Cough TDaP TDaP TDaP TDaP 白喉（DTaP疫苗/ TD___ TD___ TD___ TD___ TDAP/ TD ) / / / / / / / / 10年以内的出勤率【估计是指 【我国7岁以前总共接种5次百 破伤风 百日咳 Give n within 10 years of | 10岁以内的接种情况】 白破混合制剂的疫苗，14岁以 attendance every 10 years as 成人每10年接种一次的情况， 后是每10年接种一次】 adult, not less