Student Health Form printable pdf download

Health Form–Health Sciences

Student Health Service

When Completed, Mail Directly to:

Director, Student Health Service

Tel: (631) 632-6740

Stony Brook University

tdd: (631) 632-6171

Stony Brook, New York 11794-3191

Fax: (631) 632-6936

To Students Admitted to the School of Health Technology and Management:

The Health Sciences schools’ student health policy requires that all students admitted to programs that involve

education in clinical settings submit documentation of their health status and immunization history prior to the start of

classes. NYS Public Health Law §2165 requires all students in post-secondary education to be immunized against

measles, mumps and rubella.

In addition, NYS Public Health Law §2167 requires institutions, including colleges and universities, to distribute

information about meningococcal disease and vaccination to all students. Students must comply with

this law by reading the required information about meningitis and completing the meningococcal vaccination response

form available on your SOLAR account.

The Student Health Form has three (3) parts:

Part I – Health History; Part II – Physical Examination; Part III – Immunization History.

YOU MUST COMPLETE PART I BEFORE GOING TO A HEALTH PRACTITIONER FOR EXAMINATION.

SUBMIT THE COMPLETED FORM TO THE ABOVE ADDRESS AT LEAST 2 WEEKS BEFORE ATTENDING ORIENTATION.

The Registrar will block the registration of any student who is not in compliance. The Health Sciences schools will not

authorize students to begin their clinical education unless their physical examination, required laboratory tests, and

record of immunizations comply with the requirements listed below.

Requirements for registration and for clinical training include documentation of the following:

A. Physical examination completed by a licensed practitioner within six months of starting enrollment

(please see pages 3 and 4).

B. Required laboratory test results:

1. PPD Mantoux within six months prior to first enrollment; yearly thereafter if negative. If PPD is positive, please

submit chest x-ray and record of results, place and date of examination. Students with positive PPD and/or positive

chest x-ray will be referred to the Student Health Service for follow-up as appropriate. A copy of the chest x-ray

report is required.

2. Required Titers (showing immunity): Measles, Mumps, Rubella, Varicella and Hepatitis (unless Hepatitis B

vaccine declination statement is signed on page 4 of this form).

2.a. All required titers must have copies of full laboratory reports attached to the Student Health Form.

C. Required immunizations:

1. Tetanus or Tetanus/diphtheria (Td) toxoid within the past 10 years

2. Poliomyelitis vaccine

D. Strongly recommended immunizations:

1. Hepatitis B vaccine

2. Influenza vaccine

3. Meningococcal vaccine

4. Hepatitis A vaccine

Student Health Form