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Health forms and Health requirements for incoming students

Below you will find the full listing of the forms that will help you meet your Health Requirements for admission to Southern Connecticut State University.

To provide you with the specific Connecticut State University Student Health Services Form that will meet your needs depending on your student status, please follow the following links

 

Connecticut State University Student Health Services Form:

The following form is required for all Full-time & Part-time undergraduate students and Full-time Graduate students living on campus or choosing to receive medical care at Student Health Services.  It needs to be completed by the student and their health care provider. Requirements for adequate immunizations can be found below the Immunization Documentation Form.

 

Connecticut State University Student Health Services Form (PDF file)

in an attempt to conserve natural resources,

All Information must be submitted on this form

Please enter your dates of immunization directly on to the Connecticut State University Student Health Services Form.  Attaching additional forms from your health care provider is acceptable, but you must also write the dates onto the form which will be signed by your health care provider.  Not doing so is the most common cause of students missing required information which can result in delays in registering for classes.

 

The Connecticut State University Student Health Services Form is required for:

  • Full-time & Part-time Graduate Students
  • Full-time Graduate Students who wish to use Student Health Services
  • The deadline to return the completed Health form for Fall semester 2011 is on or before August 12, 2012
  • Graduate Students do not have a deadline for completion of health forms, however, registration can only take place AFTER health forms are completed and returned to Granoff Health services.

*All Students Residing On Campus must show proof of one dose of the Meningitis vaccine given between ages 16-18.

*All Incoming Students must show proof of adequate immunization* against Measles (Rubeola), Mumps, and German Measles (Rubella).

*All Incoming Freshmen must also show proof of adequate immunization to Chicken Pox (Varicella). Such proof must be signed by a health care provider. The only exceptions are the following:

  • Those born prior to January 1, 1957 (where applicable) 
  • Those with a valid medical exemption signed by their health care provider
  • Those who provide documented laboratory proof of immunity to Measles, Mumps, Rubella and Varicella.
  • Those who provide a statement that immunization is contrary to their religious beliefs;
  • Those who are enrolled exclusively in a program for which students  do not congregate on campus for classes or to participate in institutional-sponsored events, such as students enrolled in distance learning programs conducted entirely through electronic media in a setting without other students present.

 


 

 

Adequate immunization:

  1. Measles (Rubeola) - one injection at 12 months of age or older and on or after January 1, 1969, and a second dose at least one month later and  on or after January 1, 1980. Individuals born prior to January 1, 1957 are exempt from this requirement. 
  2. Mumps - one injection on or after 12 months of age and on or after January 1 1969  and a second dose at least one month later or on or after January 1, 1980. Individuals born prior to January 1, 1957 are exempt from this requirement.
  3. German Measles (Rubella) - one injection after 12 months of age. Individuals born prior to January 1, 1957 are exempt from this requirement.
  4. Chicken Pox (Varicella) - All incoming freshmen students will be require to show proof of 2 varicella vaccines. The doses should be separated by at least 28 days with dose number one given on or after 12 months of age. Exemptions for this include:  
    • Individuals born in the USA prior to January 1, 1980.
    • Laboratory confirmation of immunity to varicella
    • Documentation from a health care provider stating there is a medical contraindication for receiving the vaccine
    • Documentation from the student stating that such immunization is contrary to his/her religious beliefs
    • Documentation from a health care provider  or  director of health stating that the student  has had a confirmed case of such disease.
  • No titers/blood or the actual dates on a vaccination record will be accepted as proof of immunization.

 

athletic physical Form for participation in Athletics at scsu for new athletes:


Athletic Physical exam form for new  students

This form is to be filled out by the NEW incoming student and by a medical provider PRIOR to entering the university. 

The Athletic Form can be done at the same time as the Connecticut State University Student Health Services Form. Both must be submitted to participate in the Athletic program.

*These forms will not be done at the Granoff Health Center.

 

the Athletic Physical form for participation in athletics at SCSU must be filled out each year by every returning athlete.

 


Athletic examination form for returning students

The Student portion of this form is to be filled out by the RETURNING student PRIOR to June 30th. 

The returning physical assessment will be done by a provider at Granoff Health Services.