Those with the mark are fields that must be completed. / マーク は必須項目です

1.Were you a Tokyo Tech student in the previous semester?前学期に本学に在籍していましたか。
2.Is your registered enrollment period at Tokyo Tech more than three months?本学登録上の在学期間が 3ヵ月以上ですか。
3.What is your student type/category at Tokyo Tech ?本学に所属する際の身分は何ですか。
4.In which program are you going to enroll?入学予定の課程はどれに該当しますか。
5.Enter your examinee number受験番号を入力してください。

If you do not know your examinee number, please input "?"わからない方は?と入力してください。


Please enter the same name as written on your 【passport】【パスポート】に記載してある通りに入力してください。

8.Date of birth生年月日
9.Date of entrance to Tokyo Tech入学日

(Enter a planned date of arrival in Japan, if your arrival will be later than the designated date of entrance.)

10. Email address

11.Have you ever had close contact with persons known or suspected to have active TB?
12.Were you born in a country or territory that has a high incidence of active TB( countries or territories that have a high incidence of active TB.PDF), or have you stayed long term (more than 6 months)in one or more of said countries or territories?
12-1.Check all countries that apply.その国名を記入して下さい。

Please input in English英語で記入してください

13.Have you had the MMR vaccine (measles, mumps, and rubella)?M.M.R(麻疹・流行性耳下腺炎・風疹)ワクチンを受けましたか。
13-1.Have you had the measles vaccine?麻疹のワクチンを受けましたか。
13-2.Have you had the mumps vaccine?流行性耳下腺炎(おたふく風邪)のワクチンを受けましたか。
13-3.Have you had the rubella vaccine?風疹のワクチンを受けましたか。
14.Have you had the varicella (chickenpox) vaccine?水痘(みずぼうそう)のワクチンを受けましたか。
15.Have you had the tetanus vaccine?破傷風ワクチンを受けましたか。
16.Do you agree to Tokyo Tech’s use of your personal information in the way described below?

Personal Information Protection:
Your personal information will not be used for any purposes other than personal health management and preventive measures for infectious diseases on campus.
The Health Support Center at Tokyo Institute of Technology properly manages personal information and abides by the National University Corporation Tokyo Institute of Technology Personal Information Protection Rules, the National University Corporation Tokyo Institute of Technology Personal Information Management Rules, and other relevant laws and regulations regarding personal information.

また、取得した個人情報は、国立大学法人東京工業大学個人情報保護規定及び国立大学法人東京工業大学個人情報管理規定その他関係法令を遵守し、 東京工業大学保健管理センターにおいて適切に管理します。

17.file uploadファイルアップロード

Each file can be uploaded up to 7MB, so please make a total of 30MB.
We apologize for the inconvenience, but if there is not enough size to submit at one time, please submit again using this form.


●17-1.Part I: Tuberculosis (TB) Clinical Assessment Part Ⅰ(結核の臨床評価)

Upload a scanned copy of “Part I: Tuberculosis (TB) Clinical Assessment” in PDF or Zip format. You must have undergone required testing at a medical institution and had a physician complete the form.
Note: Please refer to the letter from Tokyo Tech concerning the health certificate to set a password for the PDF or Zip file before uploading it.

Part Ⅰ(結核検査)について医療機関を受診し、必要な検査を受け、医師が作成した書類を指定されたパスワードをかけてPDFかZIP形式でアップロードしてください。 指定のパスワードは健康診断書提出についての通知文を確認してください。

●17-2.Part II: Certificate of VaccinationsPartⅡ(ワクチン接種証明書)

Upload a scanned copy of “Part II: Certificate of Vaccinations” in PDF or Zip format.
If the dates on which you were vaccinated are not clear, get vaccinated again or provide documentation with antibody testing results.
For medical exemptions, please submit a letter signed by a physician stating that the vaccine is contraindicated in your medical condition.
Notes :
- Upload a scanned copy/copies of the documentation mentioned above in PDF or Zip format.
- Please refer to the letter from Tokyo Tech concerning the health certificate to set a password for the PDF or Zip file(s) before uploading it/them.


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