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Connecticut State University Student Health Services Form

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Fall Enrollment Deadline: August 1
Spring Enrollment Deadline: January 1

Additional/Optional Forms


Full-Time or Matriculating Students

  • Connecticut State Statute, Sec. 10a-155, requires that each full-time or matriculating student MUST provide proof of adequate immunization or screening against measles, mumps, rubella, varicella and tuberculosis before enrolling in the university.
  • Be sure to complete the entire form, including the  TB Risk Assessment Questionnaire (Section 6)
  • Incomplete forms will not be processed.
  • Additional requirement for students living in on-campus housing:
    • Meningitis vaccination – all students living in on-campus housing must provide proof of receiving at least one dose of meningococcal conjugate vaccine (Menactra or Menveo) not more than 5 years before enrollment.
  • Additional recommended but not mandatory immunizations:
    • Hepatitis B – to prevent a serious disease caused by a virus that attacks the liver causing lifelong infection, cirrhosis, liver failure and death.
    • Meningitis Serogroup B – Since 2015, ACIP has recommended routine use of MenB vaccines (Trumenba, Bexsero) in certain groups of individuals at increased risk for serogroup B meningococcal disease, including during outbreaks.
  • Immunization Exceptions:
    • MMR is not required for those born before January 1st, 1957
    • Varicella is not required for those born before January 1st, 1980
    • Immunization record is not required with a valid medical or religious exemption. See Request for Exception from Required Immunizations form.

Part-Time Non-Matriculating or Online Students

Although not required, the University encourages part-time non-matriculating or online students to submit the above immunizations.


Health Form Instructions

Please complete the Connecticut State University Student Health Services Form to the best of your ability. Unlike high school, there is no annual physical exam required. However, the form must be signed by a Clinician (RN, APRN, PA, MD) who can verify date of immunizations. This form is required for all full-time or matriculating students.

Part I - Immunizations

  • Questions 1-3: Provide dates of 2 Measles, Mumps, Rubella (MMR) vaccinations
  • Question 4: Provide dates of 2 Varicella (Chicken pox) vaccinations.
  • NOTE: If you are someone who doesn’t have record of immunizations, you may have labs drawn (titers) through your primary care provider or pediatrician to prove immunity. Must attach lab reports to health form. If you don’t have a clinician, Health Services will provide lab requisitions.
  • If you are living on campus, complete question #5. IF you are not living on campus, skip to #6.
  • Question 5.: Provide dates of either 1 Menactra or 2 Menveo vaccinations. The second date of immunization must be after 8/1/13. This vaccination is different from Meningitis B vaccine (Trumenba)

Part II Tuberculosis Questionnaire

  • Question 6: If you answer “yes” to parts A, B, C, or D, a PPD skin test is required. (This can be done through your primary care office or in Health Services)
  • If your skin test is positive, you will need to have a chest X-ray which assesses for active TB disease. Please provide report of X-ray.
  • If you have previously been treated for TB please provide documentation of past or current treatment.

Part III: Emergency Contact and Medical History

  • Students must list at least one emergency contact person and phone number.
  • It is important to write down allergies, medications, and serious medical or mental health concerns so we can best assist you in case of emergency.

Important

  • Forms are due August 1st for fall semester and January 1st for spring semester. Late forms may impact move-in or registration.
  • Form must be signed by each student. If under 18, is must also be signed by a parent or guardian. 

Submit Completed Form

Instructions for filling out the health form


PLEASE NOTE: A student’s CSU Health Form, immunization records and all other medical records are maintained on file at the Student Health Service office for a period of 7 years after the student leaves the University. They are CONFIDENTIAL health records and will NOT be released without written consent of the student.