INDIANINSTITUTEOFTECHNOLOGY,BOMBAY

IITBHospital

Date:________________

Allstudents*shouldreceivefollowingvaccinationspriortoadmission.

A.VaccinationCertificate

NameofVaccine DateofVaccine Doctor'sSignature

MMR(Oneboosteris
recommendedafter15yrs.Ofage)
ChickenPox(Ifnohistoryof
chickenpoxinpast)
Typhoid(Every3yrs.)

Hepatitis'A'(IfnoHistoryof
HepatitisAinpast)

B.VaccinationExemptionCertificate:

Mr./Ms._______________________________issufferingfrom_______________________
and is on ______________________________ treatment. Hence, vaccination is
contraindicatedinhim/her.

RegisteredMedicalPractitioner

* Only those students in whom vaccination is medically contraindicated will be

exempted from these vaccinations on provision of medical certificate by registered
medicalpractitioner.

______________________________________________________________________________