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 who both stayed in Japan during the previous semester and submitted a health certificate?前学期に本学に在籍かつ来日し、健康診断書を提出しましたか。
2.Is your registered enrollment period at Tokyo Tech (the period during which you are officially registered as a student in Tokyo Tech, i.e. from your entrance date to your graduation/completion date) three months or longer?本学登録上の在学期間(東京工業大学の学生として正式に登録されている期間、入学日から卒業・修了日まで)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 student ID学籍番号を入力してください。

If you do not know your student ID number, please input a question mark "?"学籍番号がわからない方は「?」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.Your age at the time of submission.提出時の年齢を入力してください
10.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.)

11. Email address

12.Have you ever had close contact with persons known or suspected to have active TB?
13.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?
13-1.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

14.Which record of MMR vaccination (antibody test results or vaccinated dates) will you submit?MMR予防接種歴について、以下のどちらを提出しますか?
15.Which record of varicella (chickenpox) vaccination (antibody test results or vaccinated dates) will you submit? 水痘(みずぼうそう)の予防接種歴について、以下のどちらを提出しますか?
16.Have you had a booster dose of the T-dap vaccine during the past 10 years? (If not, you must be vaccinated.)T-dapのブースター接種について回答してください。※ブースター接種を10年以内に受けていない場合は必ず受けてください。
17.Do you agree to Tokyo Tech’s use of your personal information in the way described below?

The collected personal information will be managed in compliance with all the laws and regulations regarding personal information for all the Tokyo Tech students, and will not be used for any purposes other than those indicated in the Policy on Protecting the Privacy of Students, Faculty, and Staff at the Health Support Center:Policy on Protecting the Privacy of Students, Faculty, and Staff at the Health Support Center PDF


18.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.


●18-1.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.

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PDFかZIP形式でアップロードしてください。

Tuberculosis (TB) Screening Test Results結核スクリーニング検査の結果

●18-2.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.
Provide antibody testing results or dates of 2doses of vaccinations. Without clear evidence of the dates, you must undergo antibody testing and complete the medical certificate. In such cases, if the results are negative/equivocal, you must be vaccinated and also fill out the dates you were vaccinated in the medical certificate.
For medical exemptions, please submit a letter signed by a physician stating that the vaccine is contraindicated in your medical condition.
Note: Upload a scanned copy/copies of the documentation mentioned above in PDF or Zip format.


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