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Mandatory Health Requirements Checklist and Letter for Seniors for 2021-22 School Year
Tue, Jun 1, 2021 10:17 AM
Dear Parent/Guardian:

All students entering 12th grade for the school year 2021-2022 in the State of Illinois are required to show proof of having one dose of Meningococcal conjugate vaccine on or after their 16th birthday, OR two doses of the vaccine at least 8 weeks apart with one of the vaccines being given on or after the 16th birthday.

Please provide verification of one of the following:

  • A dose of Meningococcal vaccine administered on or after your child’s a6th birthday (only one is needed)
  • Two doses of the Meningococcal vaccine at least 8 weeks apart and the second one being given on or after the 16th birthday.
Proof of having received the Meningococcal vaccine is required and should be submitted to the School Nurse as soon as the vaccine is given.

For documentation, you may use the form below.  Forms can also be found on the nurse’s webpage on Ottawa Township High School’s website under the Parent Resources tab, or your health care provider may use their own form.

Completed forms may be:

  • Dropped off in the Nurse’s Office, Room 205.
  • Mailed to OTHS, Attention: Nurse’s Office
  • Scanned and emailed to the Nurse's Office at
  • Faxed to the Nurse at (815) 431-2461.
A mandatory health requirement checklist is attached for your reference.
If you have any questions, please contact the Nurse’s Office at 815-431-2461.


Trisha Modeen, MSN RN PEL-CSN
OTHS School Nurse


Child’s Name:  _____________________   

Date of Birth:  ____________________________

Meningococcal Conjugate Vaccine #: _________________________  

Expiration: ___________________

Date Vaccine Given: ___________________________

Physician/APN Signature and Stamp: