Section 694.APPENDIX C   Required Elements of Health Record

1.         Name

2.         Student Identification Number

3.         Month, Day and Year of Birth

4.         Gender

5.         Term and Year of First Entry

6.         Dates to Establish Immunity to Measles (Rubeola)

7.         Dates to Establish Immunity to Rubella

8.         Dates to Establish Immunity to Mumps

9.         Dates to Establish Immunity to Tetanus/Diphtheria

10.         Date of Most Recent Tetanus/Diphtheria/Pertussis Booster (Tdap)

11.         Date of Most Recent Meningococcal Vaccine

12.         Phone Number of Certifying Health Care Provider

13.         Name and Signature of Health Care Provider

(Source:  Amended at 40 Ill. Reg. 10715, effective July 21, 2016)