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Connecticut State University Student Health Services Form

Download Connecticut State University Student Health Services Form

Fall Enrollment Deadline: August 1
Spring Enrollment Deadline: January 1

  • Connecticut State Statute, Sec. 10a-155, requires that each full-time or matriculating student MUST provide proof of adequate immunization or screening against measles, mumps, rubella, varicella and tuberculosis before enrolling in the university.
  • Be sure to complete the entire form, including the  TB Risk Assessment Questionnaire (Section 6)
  • Incomplete forms will not be processed.
  • Additional requirement for students living in on-campus housing:
    • Meningitis vaccination – all students living in on-campus housing must provide proof of receiving at least one dose of meningococcal conjugate vaccine (Menactra or Menveo) not more than 5 years before enrollment.
  • Additional recommended but not mandatory immunizations:
    • Hepatitis B – to prevent a serious disease caused by a virus that attacks the liver causing lifelong infection, cirrhosis, liver failure and death.
    • Meningitis Serogroup B – Since 2015, ACIP has recommended routine use of MenB vaccines (Trumenba, Bexsero) in certain groups of individuals at increased risk for serogroup B meningococcal disease, including during outbreaks.
  • Immunization Exceptions:
    • MMR is not required for those born before January 1st, 1957
    • Varicella is not required for those born before January 1st, 1980
    • Immunization record is not required with a valid medical or religious exemption. See Request for Exception from Required Immunizations form.
    • Distance Learners are exempt from the immunization requirements if all courses are on-line.

Optional forms


PLEASE NOTE: A student’s CSU Health Form, immunization records and all other medical records are maintained on file at the Student Health Service office for a period of 7 years after the student leaves the University. They are CONFIDENTIAL health records and will NOT be released without written consent of the student.