New Students CSU Student Health Services Form
Connecticut State University Student Health Services Form (pdf)
This form is required for all incoming full-time & part-time students. It needs to be completed by the student and their health care provider.
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. 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 students
- The deadline to return the completed Health form for Spring semester 2014 is at or before your New Student Orientation (NSO)
All incoming freshmen students must show proof of adequate immunization* against Measles (Rubeola), Mumps, German Measles (Rubella) and 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.
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.
Chicken Pox (Varicella) - All incoming 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 Chicken Pox include:
- Individuals born in the USA prior to January 1, 1980
- Laboratory confirmation of immunity to varicella (include lab report)
- 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.