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FULL TIME STUDENTS HEALTH FORM:
All FULLTIME
students are required to submit a completed medical form that includes
a medical history, Immunization data and a physical examination by a
health care provider
prior to registration at the University according to
the deadline noted on the medical form
(dates change per semester)
If you are an international student, you can click on the link below to
read all the information
you will need to know. (international
student information)
MEDICAL INFORMATION REQUIREMENTS:
a. Your Medical History
to be filled out by you- first three pages of the form
Tuberculosis
Risk Questionnaire: page 3 of the health history. Guidelines are
listed for those who will need to have the
skin test and those who will not. All Counseling and Family
Therapy Majors will need to have the Tuberculin Skin Test required as
part of their program.
b. A
Physical Examination including laboratory tests
all performed within the year prior to the start of
your academic year.
Laboratory
tests: A recent hemoglobin/hematocrit along with a urinalysis is
required for all
varsity athletes.
Cholesterol tests are not required but highly recommended.
c. Your Immunization History
(see below for guidelines to the
requirements)
1. Two
Measles vaccinations
The dates for two vaccinations must be entered in
the medical form:
a. The first vaccination must have been given to you after January1.1969
and after
the first birthday;
b. The second
shot must have been administered after January 1. 1980.
c. If
you have had the disease:
Listing the
information is not sufficient proof of immunity.
1.
A
blood test is required to verify immunity.
2.
Please
consult you physician if you need to order a blood test. A copy of
the blood
test laboratory results must be attached to this form.
2.
One
Rubella vaccination:
a. One
dose administered after your first birthday which must have occurred after
June,1967.
This will be sufficient to be submitted as
proof of immunity.
b. If
you have had the disease, listing the information is not sufficient proof
of immunity. A
blood test is required to verify
immunity. Please consult you physician if you need to order
a blood
test. A copy of the blood test laboratory results must be attached
to this form.
3. Tetanus
Vaccination: within the last 10 years
4. Menomune/Menactra Vaccination: aka "meningitis vaccine" – required only for residence
hall students. link for information on
Menomune/
Menactra(including subtypes A,C,Y, W-135 in
the vaccine)
5. The
Hepatitis B Vaccine Series is not mandatory but is strongly recommended.
Counseling and Family
Therapy majors will be required to have this series of vaccination
for their
program submitted on a
separate form.
6. Mumps Vaccination: will be required in
Fall 2009. Many of you have received this as it is part of
the MMR vaccination.
EXEMPTIONS for IMMUNIZATIONS:
a. AGE: If you were born before 1957, you are exempt
fro this immunization requirement of Measles and Rubella. We ask
that you please submit the medical form omitting the dates for these two
immunizations.
b. MEDICAL - Written documentation from
licensed physician must be attached to this
form to be exempt from the required vaccinations for
medical reasons. Along with the
medical form, please submit the “Exemption” form that
you can download under
“forms” at the end of this page.
c. RELIGIOUS
– please submit a letter from your religious
affiliation.
FULL TIME FORMS:
1.
FOR INCOMING
FALL 2008 (click on links below for the appropriate form)
GENERAL STUDENT
INFORMATION
VARSITY
STUDENT ATHLETE INFORMATION
INTERNATIONAL STUDENT INFORMATION
2.
Exemption
Form:
for immunization exemption - to
be submitted with the necessary documentation
listed
under “Exemptions” in the above paragraph.
SUBMITTING
THE FORM
Mail
Central
Connecticut State University Health Service
1615 Stanley Street
New Britain, Ct. 06050
Fax
860-832-2579 (not the preferred method due to possible difficulties in reading the fax)
In Person
University
Health Service
Marcus White Annex
for directions on campus:
Location,
Directions and Parking
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