Required Health Forms
These forms, in PDF format, are downloadable and printable. Please print only the forms that are necessary for you. You do not need to complete the other one that do not apply.
full-time undergraduate & graduate students
Complete Health Form (PDF file)
This is the five (5) page health form needed to fulfill the health requirements for:
- This form is mandatory for full-time undergraduate students
- This form is required for full-time graduate students who would like to use Student Health Services
part-Time undergraduate & graduate students
Immunizations documentation (PDF file)
MMR - Measles (Rubeola), Mumps, and German Measles (Rubella)
This form is required for:
- Part-time matriculated undergraduate students
- All matriculated graduate students
additional forms
These additional forms are ONLY necessary if you utilize the service.
AUTHORIZATION TO RELEASE INFORMATION (PDF file)
This form is only required for students wishing to release Health Information to another facility. It is not required for incoming students!
This form allows Granoff Student Health Center to release information:
- to you
- to another school
- to another Health Care Provider
- other campus authorities, as warranted and/or as stipulated by the student
Print out and fill in the form, including all required information and
FAX it to 203-392-6301 or
Send it to Granoff Health Services
501 Crescent Street
New Haven, CT 06515
WOMAN'S HEALTH FORM (PDF)
This form is to be completed prior to an annual GYN exam and brought to Health Services with you. It is not required for incoming students!
This will save you time at your appointment. If not brought in with you, it will have to be completed prior to your appointment time.
Application for special parking ( pdf)
The special parking permit is intended for short-term medical parking and must be accompanied by a doctor's note specifying the duration of the parking request and the medical reasons for the special parking. This form should be filled out and taken to Granoff Student Health Services where it will be evaluated and signed by a medical provider.
The signed form must then be taken to Campus Police where the special parking permit will be issued.
The special parking permit is intended for short-term medical problems. If the student has a chronic condition and more time is needed, then the student should obtain a State of Connecticut Handicapped parking permit.
excused absence policy(pdf)
This is the form to print if your professor requires a note from health services.
Student Health Center will not routinely issue medical excused absence notes for confirmation of illness.
The Student Health Center medical staff will provide a medically excused absence note only if the student was treated at the health center and the student must have been absent from class for six (6)or more days for medical reasons.
A student who is absent from class less than six (6) days for a medical reason should discuss the issue with his/her professor. If a professor requires a note for a medical absence of less than three days, a written request on university letterhead must be submitted to the Student Health Center by the professor.
The Student Health Center medical staff will not write excused absence notes for illnesses or problems for which we never provided care. If you received care for your illness or injury from your private provider, the emergency room or a clinic in the community, you should request your excused absence note from that medical provider rather than from the Student Health Center.
