Keio University Hospital / Keio University Shinanomachi Campus

Immunization Record (International Student)
Name

Katakana Name

EmailMeasles, Mumps, Rubella, Varicella (MMRV): Please fill out section (1) or (2) for each disease.
（1） History of viral vaccination (2 Inoculations)
Date of Vaccination

Measles

Mumps

RubellaVaricella① (YYYY-MM-DD)② (YYYY-MM-DD)（2） Antibody Test Results and Related Immunization History
Measles

Mumps

RubellaVaricella

IgG(EIA) / NT

IgG(EIA)

IgG(EIA) / HI

IgG(EIA) / IAHA

Negative / Positive /Negative / Positive /Negative / Positive /Negative / Positive /Strongly Positive

Strongly Positive

Strongly Positive

Strongly Positive

Date of Testing(YYYY-MM-DD)

Method (circle method)
Measurement values
Result (circle result)
Date of Vaccination ①(YYYY-MM-DD)

Date of Vaccination ②(YYYY-MM-DD)

Hepatitis B: Please fill in only if the applicant is engaged in work or research that may involve exposure to bodily
fluids, such as the handling of instruments or medical waste contaminated with body fluids, treatments involving contactwith body fluids, blood sampling, testing, or specimen handling.

（1） 3-dose primary vaccination series①②③

If unknown:

Date of Vaccination(YYYY-MM-DD)(approx. year)（2） Have the applicant ever had a positive HBs antibody test result (10mIU/mL or more) after
receiving a primary vaccination series or booster dose?

□ Yes□ No（3） If the answer to (2) is "Yes", please fill in the box below:
Date of Testing (YYYY-MM-DD)

Method (circle method)

Measurement values

CLEIA / CLIAｍIU/ml(4) If the answer to (2) is "No", the applicant may have insufficient immunity to hepatitis B. The applicant must consult
a medical institution regarding additional booster doses and submit this certificate after consultation. If the HBs
antibody titer of the applicant is less than 10mIU/ml even after receiving booster doses (vaccine non-responders),or if you are pregnant or cannot receive the vaccination due to allergies, etc., please indicate so in the notes section.

V1.4E

Keio University Hospital / Keio University Shinanomachi Campus

For the Health Care Provider:
Before creating this certificate, please refer to the applicant's Maternal and Child Health Handbook, antibody test results,
and vaccination certificates, and confirm that the applicant meet the standards of our hospital.
＜MMRV＞ Applicant must meet one of the following conditions ①–③ for each MMRV disease:① Proof of two previous vaccinations② Proof of previous positive antibody test results (any year) and proof of a subsequent vaccination③ Proof of previous strongly positive antibody test results (any year)==================================================================================================＜Hepatitis B＞ Applicants must meet the following condition:《Only required for those engaged in work or research that may involve exposure to bodily fluids, such as the handling of instruments or medical
waste contaminated with body fluids, treatments involving contact with body fluids, blood sampling, testing, or specimen handling.》

The applicant has already received a hepatitis B primary vaccination series and has confirmed an antibody titer of ≧10 mIU/ml(CLEIA/CLIA) considered a reliable marker of protection against infection.
※Consult the table below for definitions of negative, positive, and strongly positive MMRV results.
※Antibody testing is valid for the following methods only:
Measles: IgG-antibody titer determined by enzyme-immunoassay (EIA) or neutralizing antibody titer (NT)Mumps: IgG-antibody titer determined by enzyme-immunoassay (EIA)
Rubella: IgG-antibody titer determined by enzyme-immunoassay (EIA) or hemagglutination inhibition (HI) antibody titer
Varicella: IgG-antibody titer determined by enzyme-immunoassay (EIA) or immune adherence hemagglutination (IAHA) titer
Antibodytiter

Negative

Positive

Strongly Positive

EIA

Other

EIA

Other

EIA

Other

Measles

below 2.0

NT of less than 4

2.0-15.9

NT of 416.0 or higher

NT of 8 or higher

Mumps

below 2.0－

2.0-3.9－

4.0 or higher－Rubella

below 2.0

HI titer of less than 8

2.0-7.9

HI titer of 8-16

8.0 or higher

HI titer of 32 or higher

Varicella

below 2.0

IAHA titer of less than 2

2.0-3.9

IAHA titer of 2

4.0 or higher

IAHA titer of 4 or higher

DiseaseVaccination series

2 doses of vaccine following examination

1 dose of vaccine following examination

Vaccination not required

Tuberculosis Screening (PPD or IGRA (QFT, T-spot)) within last 12 months.
(1) Please fill in the box below.
Date of Testing (YYYY-MM-DD)

Method (circle method)

Result (circle result)

PPD / IGRA (QFT , T-spot)

Negative / Positive(2) If PPD or IGRA (QFT, T-spot) is positive, a chest X-ray is required. Please fill in the box below.
Date of X-ray (YYYY-MM-DD)

ResultTetanus / Diphtheria (primary series plus booster within last 10 years).
Please fill in the box below.

Date of Vaccination (YYYY-MM-DD)

Date of Booster (YYYY-MM-DD)

Notes：
I certify that the above information is accurate to the best of my knowledge.
Date:

Name of Health Care Provider / Address;
Physician Name;【Personal information is shared between the International Office, the Health Center, and the Center for Infectious Disease and Infection Control; and as a rule isnot shared with any third parties. However, in exceptional circumstances such as urgent situations regarding hospital infection; complying with law; or situations
in which it is necessary to protect an individual’s life, property, or wellbeing; personal information may be shared with third parties without the individual’s consent.
Data (except identifying personal information) may be used for education, research, or lectures.】

For inquiries about this form: Keio University Health Center, Shinanomachi branch Tel: 03-5363-3634