Connecticut State University Student Health Services Form

ADVERTISEMENT

Connecticut State University Student Health Services Form
This Connecticut State University Student Health Services Form is mandatory and
the only form that will be accepted as proof of vaccination. All information must be
entered on the form. Entering or stamping, “See Attached,” may delay the processing
of your form. We encourage attaching immunization records but dates must be
entered on form. Please make this clear to your healthcare provider’s office when
you drop off the form.
All students, including transfer and exchange students, and those changing from part-time to
full-time status, are required to submit this form to University Health Service no later than July
15 for the fall semester and December 15 for the spring semester. Proof of adequate
immunization against measles, mumps, rubella (MMR) and varicella (chicken pox) and
completion of the Tuberculosis (TB) Risk Assessment are required. Failure to meet this
requirement will affect your ability to register for classes or change your schedule. Part-time
students are not required to have a clinician signature on the “Physical Examination
Affirmation.” Page two is also optional for part-time students.
Guidelines for these state immunization requirements are below. If your form is submitted with
any missing information, we will notify you requesting the necessary data. Make sure your
correct contact information is updated on your WebCentral/Student Pipeline account.
Messages regarding your health information requirements can also be seen on your
Registration Status in your WebCentral account.
PLEASE NOTE TRANSFER STUDENTS: Your health information is not automatically
transferred with your academic records from your prior university. You must submit a
completed form with all required information as if you were a first time college student.
Transfer students, like other incoming full time students, are required to provide proof of
adequate immunization against measles, mumps, rubella (MMR) and varicella (chicken pox)
along with completion of the Tuberculosis (TB) Risk Assessment.
University Health Services is here to assist you in the successful completion of your academic
journey. If you encounter any difficulty in getting the required information or you have any
questions please call us at (860) 832-1925. We are here to do everything we can to make
your transition to life at CCSU as easy as possible. Please look our webpage,
, for more information about the services we offer.
Congratulations on your admission to CCSU!
University Health Services
Christopher Diamond, MD, Director
Marisol Aponte, APRN, Associate Director
Revised 6/14/14

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 4