University of Connecticut University of UC Title Fallback Connecticut

Forms

Student Health History Form – includes both Form A & Form B – required for all campuses EXCEPT School of Social Work (see SSW form below.) NOTE: Apple Preview should not be used to complete these forms.

  • Deadlines: July 1 for the Fall semester and January 1 for the Spring semester.
  • Connecticut state law requires that your healthcare provider completes/verifies your immunization information in writing (Form A)
  • For more information on immunization requirements, click here.
  • Failure to submit your immunization history by the 10th day of classes will result in your inability to register for classes.
  • Information about the Health History Form is sent to each newly admitted student after your deposit is received. If you did not receive this info, the new student packet can be found here.
  • Students enrolled in the Medical, Dental or Graduate schools at UCHC in Farmington should contact their school for health history requirements as they may differ from those stated here.

School of Social Work Vaccination Record

  • Deadline: June 1.
  • NOTE: This form is required prior to starting any coursework at the School of Social Work.

Clinical Rotation Health Review Form

  • In addition to the Student Health History Form, students on Clinical Rotations are required by practice sites to provide specific information about their current health and immunization status.

Tuberculosis (TB) Assessment

  • NOTE: This form is only for students who previously submitted all of the required immunization information and are notified that they are missing the TB assessment (i.e. Regional Transfer students.)

Consent for Treatment

  • For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order for you to receive prompt care and treatment should the need arise.

Women’s Health History

  • If you have scheduled an appointment for a Women’s Health exam, you may have been instructed to print and complete this form. Please bring it with you to your appointment.
  • Print this form in black ink and complete using a black or blue pen.
  • This form contains some very explicit questions that help our clinicians in evaluating your health risks. You are not obligated to answer any questions which make you feel uncomfortable.

DOT Medical Exam Form

Two forms must be brought with you to your scheduled DOT Medical Exam:

  • Section 1 Driver Information of the DOT Medical Exam Form. This includes the Personal Information section and the Driver Health History section on pages 1 and 2. It is a fillable-PDF that can be filled out and printed. Then sign and date the driver certification statement. Failure to complete this form ahead of time and bring it with you will result in rescheduling of your appointment.
  • In addition to the Exam Form, please fill out and print the DOT Medical Certificate with the driver name, address and license info. The medical provider will complete her portion after your examination.

Club Sports Participant Clearance to Play Form

  • Beginning Fall 2017, all Club Sports athletes will be required to fill out a Clearance to Play form. Participants must have the signature of their healthcare provider verifying they have had a physical examination within one year of the season’s start date.

Meningitis Vaccination Documentation Form

  • Students who need to submit only their meningitis vaccination information can download, complete, and submit this abbreviated form to Student Health Services.

Immunization Exemption Form

  • If you require exemption from the university’s immunization requirements, please print, complete and return this form. Please note that if your request exemption for either medical or religious reasons, you may be excluded from campus in the event of an outbreak of a disease for which immunizations are required. For more information on immunization exemptions, click here.

Authorization for Release of Health Information

  • If you need to have a copy of your Student Health Services medical record sent to another medical provider, please print and complete this release of information form. You will need to provide your name and other identifying information as outlined on the form, the type of information you need and where/to whom you would like it sent. Your request will be processed within 2 weeks of receipt. Please be sure to include your telephone number in the event we need to contact you.
  • Print, complete and mail/fax the form as indicated on the form. (To respect your privacy, we discourage the faxing of information.)

Vaccination Clinic Permission Forms

If a student is under 18 years of age at the time of vaccination, the signature of a parent or guardian is required.