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full-time & Part-Time undergraduate Transfer students

This form is required for all incoming full-time & part-time transfer students.  It needs to be completed by the student and their health care provider. Requirements for adequate immunizations can be found below the Complete Health Form.

 

Connecticut State University Student Health Services Form (PDF file)

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.

  • This form is mandatory for full-time & part-time undergraduate transfer students
  • The deadline to return the completed Health form for Fall semester 2013 is on or before August 12, 2013

 

All matriculated undergraduate students (full-time and part-time) must show proof of adequate immunization* against Measles (Rubeola), Mumps,  and German Measles (Rubella). 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, and Rubella.
  • 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:

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.

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.

German Measles (Rubella) - one injection after 12 months of age. Individuals born prior to January 1, 1957 are exempt from this requirement.