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Forms

University Requirements for Health Information & Insurance:

Each student is required to have the following documents on file at the Health Center.

  1. Report of Medical History and Physical Exam Form
  2. Immunization Records
    *  Measles, Mumps, Rubella Vaccine
    *  Tetanus Shot
    *  Meningitis Vaccine
    *  Polio
    *  Hepatitis B Vaccine
    *  Varicella (Chicken Pox)
    *  Tuberculosis
Instructions:

Be sure to follow all instructions carefully.  Incomplete records will be returned and delay registration. 

1.  Report of Medical History and Physical Exam Form
  • Pages 1-3 are to be completed and signed by the student or guardian (if student is a minor)
  • Pages 3-4 are to be completed and signed by your physician
2.  Immunization Records
  • Measles, Mumps, Rubella Vaccine:  Evidence of immunization or titers
  • Tetanus Shots:  Date of shot must be within 10 years of the date of registration.
  • Meningitis Vaccine:  Evidence of immunization or titers
  • Polio:  Evidence of immunization or titers
  • Hepatitis B Vaccine:  Evidence of immunization or titers
  • Varicella (Chicken Pox):  Evidence of immunization or titers
  • Tuberculosis:  PPDA or IGRA within 6 months of registration.  If positive a copy of chest x-ray and any treatment information is required.

Forms

Click below for a copy of the Welcome Letter

 

Medical History & Physical Exam From