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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

FULL-TIME OR MATRICULATING STUDENTS

  • 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.

PART-TIME NON-MATRICULATING OR ONLINE STUDENTS

  • Although not required, the University encourages part-time non-matriculating or online students to submit the above immunizations.

  1. This form is mandatory for all full-time or matriculating students.
  2. Forms are due August 1st/ January 1st. Late forms may impact move-in or registration.
  3. No physical exam required! Provider just needs to sign to verify accuracy of information.
  4. Must have proof of having 2 Measles, Mumps, Rubella (MMR), & Varicella (Chicken pox) vaccinations.
  5. If you don’t have your immunization records, you may have labs drawn (titers) to prove immunity. Must attach lab reports to health form.
  6. If you are living on campus you must have 1 Menactra or Menveo vaccination within 5 years from the date of enrollment. This protects from Meningitis A, C, Y, W. Students will not be allowed to move on campus without proof of having received this vaccine. This is different from the Meningitis B vaccine Trumenba, which is highly recommended in the college population.
  7. You must answer questions in # 6. If you answer “yes” to any question, you must get a PPD skin test (available in Health Services) which screens for TB. If your skin test is positive, you must have a chest X-ray and provide X-ray report stating that you are free from disease. If you have been treated for TB you must provide documentation of past or current treatment.
  8. It is important to write down allergies, medications, and serious medical or mental health concerns so we can best assist you in case of emergency.
  9. Students must list at least one emergency contact person and phone number.
  10. Students must sign the form. If under 18, form must also be signed by a parent or guardian.
  11. Fax completed form to 203-392-6301 or send by mail to Granoff Health Center, 501 Crescent Street, New Haven, CT 06515

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.