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Health Forms

Connecticut State University Student Health Services Form

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Fall Deadline: AUGUST 1ST

Spring Deadline: JANUARY 1ST

Optional Forms


Health Form Instructions 

Part I - Documentation of Immunizations

TWO MEASLES, MUMPS, RUBELLA (MMR) vaccinations. First must have been given after first birthday. MMR vaccines are not required for those born before January 1st, 1957.

 - TWO VARICELLA VACCINATIONS OR PROOF OF DISEASE. Not required for those born before January 1st, 1980.  

- IF LIVING ON CAMPUS: ONE Meningococcal Meningitis Vaccine (Menactra or Menveo) received within 5 years of enrollment. Please note this vaccination is different from Meningitis B vaccine (Trumenba, Bexsero).    

 

Part II Tuberculosis Risk Questionnaire 

- ALL students must answer the Tuberculosis Risk Questionnaire. 

- If “yes” to any part of #6, the student must provide proof of having a PPD skin test or quantiferon/T-spot blood test within the last 6 months. PPD skin testing and blood testing is available to all registered students by appointment for a small fee. Schedule appointment https://patient-southernct.medicatconnect.com/login.aspx  

- If skin test is positive the student will be required to undergo a chest x-ray evaluation or provide x-ray reports documenting freedom from disease within the last 5 years. If student has ever been treated for TB they must provide documentation of treatment and freedom from active disease. 

Part III: Emergency Contact and Medical History 

  • List at least one emergency contact person and phone number.
  • Write down any life-threatening allergies including those to foods and medications. 
  • List any serious medical or mental health concerns so we can best assist them in case of emergency.  

Part IV: Submitting a Completed Form 

  • Submit Online: Click hereMedicat Health PortalLog in using your banner ID and password. Follow instructions to upload data and allow 24-48 hours for processing.    OR...
  • Email:healthservices@southernct.edu, please include a PDF attachment     OR...
  • Fax: (203) 392-6301 (Please send 1 copy and allow 24-48 hours for processing.     OR...
  • Mail:Student Health Services, Granoff Building, 501 Crescent Street, New Haven, CT 06515  

We encourage students to promptly return any missed calls from Health Services and to check their SCSU email frequently for any outstanding health requirements. Once your health form has been submitted and processed you will receive an email communication verifying compliance. Any Health Services communications will then be sent via secure message through the Medicat Health Portal.

Points to remember:

1. Form must be signed.Students under 18 require a signature from a parent or legal guardian. PLEASE NOTE: Health Services is not authorized to provide medical care to minors under the age of 18 without parental or legal guardian signature.

2. No physical exam or health assessment required.  Students may print and complete the form by referencing the dates on their immunization records.  Attach a copy of immunization records when submitting your form.

3. Form is required for full-time or matriculating students. Connecticut State Statute, Sec. 10a-155, requires students to submit a Connecticut State University Health Form providing proof of adequate immunization or screening against Measles, Mumps, Rubella, Varicella and Tuberculosis.  Non-matriculating part-time and online students are not required to submit a health form.

4. If unable to provide record student may have lab bloodwork drawn to prove immunity. Lab reports must be submitted with health form. Please contact the students' primary care or pediatrician's office to request lab services. Student Health Services does not provide immunizations. To find immunization clinics near you go to  vaccinefinder.org

5.  Immunization records are not required for those with valid medical or religious exemptions Appropriate documentation must be submitted prior to due date. Requests may need approval by the Medical Director. Students requesting exemption are still required to submit a signed health form providing documentation of having completed the Tuberculosis Risk Questionnaire and listing emergency contact information. Download and complete the Medical/Religious Waiver Request (pdf).


Need a little more help? See below for a visual guide for completing health forms 

Instructions for filling out the health form