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.

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:

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 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: