Connecticut State University Student Health Services Form
- Release of Information/Request for Records
Health records are maintained on file for a period of 7 years after the student leaves the University and may not be released without written consent of the student.
- Medical/Religious Waiver Request
- Varsity Athletics
- Club sports pre-participation evaluation.
- Medical Parking Permit Form
Health Form Instructions- Please read carefully
HEALTH FORMS MUST BE SUBMITTED NO LATER THAN AUGUST 1ST FOR FALL SEMESTER ANDJANUARY 1ST FOR SPRING SEMESTER. FORMS RECEIVED LATE MAY IMPACT REGISTRATION AND ON-CAMPUS HOUSING.
THE CSU HEALTH FORM (FOR ENROLLMENT IN A COLLEGE OR UNIVERSITY) IS DIFFERENT FROM THE HEALTH ASSESSMENT FORM(USED IN ELEMENTARY AND HIGH SCHOOL). PLEASE DO NOT SUBMIT THIS FORM AS IT WILL NOT BE ACCEPTED.
Connecticut State Statute, Sec. 10a-155, requires full-time or matriculating students to submit a Connecticut State University Health Form providing proof of adequate immunization or screening against Measles, Mumps, Rubella, Varicella and Tuberculosis prior to enrollment. Part-time, non-matriculating and online students are not required to submit a health form.
Students must sign their health form. 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.
We do not require documentation of physical exam or health assessment. Students may print and complete the form by referencing the dates on their immunization records. Once completed, a student may then bring the completed form to their healthcare provider who can then verify and sign. If possible, attach a copy of immunization records when submitting your form.
Immunization records are not required for those with valid medical or religious exemptions. Requests for Exemption must include associated documentation, be submitted prior to due date, and will need approval by the Medical Director. Students requesting exemption are still be required to submit a signed health form providing documentation of having completed the Tuberculosis screening questionnaire and listing emergency contact information. Click here for Medical/Religious Waiver Request
INSTRUCTIONS FOR COMPLETING THE HEALTH FORM:
Part I - Documentation of Immunizations
- Questions 1-3:
- Provide dates of TWO MEASLES, MUMPS, RUBELLA (MMR) vaccinations. First MMR must have been given AFTER first birthday. MMR vaccines are not required for those born before January 1st, 1957. If unable to provide record of immunizations student may have labs titers 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
- Question 4:
- Provide dates of TWO VARICELLA VACCINATIONS OR PROOF OF DISEASE. Varicella vaccine or proof of disease is not required for those born before January 1st, 1980. If unable to provide immunizations, student may have labs titers 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.
- Question 5- For those who intend to live on campus
- Provide proof of at least one of Meningococcal Meningitis Vaccine (Menactra or Menveo). Vaccine must have been given within 5 years of enrollment. Those who received this immunization greater than 5 years ago will be asked to reimmunize. To find immunization clinics near you go to vaccinefinder.org Please note this vaccination is different from Meningitis B vaccine (Trumenba)
- If not living on campus- skip to question #6
PartII Tuberculosis Questionnaire
- Question 6:
- ALL students must answer the TB screening 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. If the student has had a positive PPD or positive blood test in the past and subsequently underwent a chest x-ray, Health Services will accept 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
- On page 2, list at least one emergency contact person and phone number.
- Write down any life-threatening allergies including those to foods and medications.
- We encourage students to 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 here: Medicat Health PortalLog in using your banner ID and password. Follow instructions to upload data and allow 24-48 hours for processing. OR...
- Email:firstname.lastname@example.org, 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.
- Need a little more help? See below for a visual guide for completing health forms