Health Forms & Health Requirements

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 and Graduate students. The form needs to be completed by the student and their health care provider.

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 have your healthcare provider enter your dates of immunization directly onto 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.

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

Full-time & Part-time Undergraduate Students
Full-time & Part-time Transfer Students
Full-time & Part-time Graduate Students

*All Students Residing On Campus must show proof of Meningitis vaccination. The first dose of Meningitis vaccince at age 13-15 years and a 1-time booster dose should be administered, preferably between ages 16-18, before the peak in increased risk of disease. Persons who receive their 1st dose of meningococcal conjugate vaccine at or after age 16 do not need a booster dose.

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

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:

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 are required 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.

Additional Requirement for On-Campus Resident Students:

Connecticut state statutes also require that all students living in on-campus housing are required to be vaccinated against Meningitis within the last five years with the following exceptions:

1. Those with a valid medical exemption signed by their health care provider

2. Those who provide a statement that immunization is contrary to their religious beliefs

Documentation must be submitted to the university health service prior to moving into on-campus residence halls. The university reserves the right to deny registration and campus housing to any student not in compliance with the above health requirements.

Accident insurance protection is part of the General Fee paid by all full-time students. In addition to the accident coverage, the university also requires a sickness insurance plan to cover some surgical expenses and hospitalization costs. Full-time students will be automatically enrolled in and billed for the sickness insurance plan unless they waive the insurance on-line at www.aetnastudenthealth.com. Details of both plans are in a brochure distributed by the university to each student or on-line at www.aetnastudenthealth.com. In the event of accident or sickness, students can obtain a medical claim form on-line www.aetnastudenthealth.com. Students are advised to consult the health insurance brochure available from the university health service or www.aetnastudenthealth.com for additional information.

Athletic Physical exam form for new students

This form is to be filled out by the incoming student's healthcare provider.

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.

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.