This is the form for all students
(full and part-time, graduate and undergraduate).

Please use this form only.

This is a Word document

It must be completed with your registration/acceptance to the University.
Documentation must be clearly legible and have school ID number or social security number
clearly written.

This form must be signed or stamped by your physician!!

Fax form to: 860-768-5140 or by mail:
Student Health Services
University of Hartford
200 Bloomfield Avenue
W. Hartford, CT 06117

Before beginning school, all students must submit Immunization Records. This includes Undergrads, Graduate, Part-time and Full-time students.
A physical is not required!

The State of Connecticut mandates that all students
supply the following information:

1. All students must show proof of 2 MMR’s (measles, mumps, rubella). (You are exempt if you are born before 12/31/56). Disease history is not acceptable for this requirement.
   Please contact health services if you are age exempt.
   
   
   
2. All students must show proof of 2 varicella (chicken pox) vaccines. Documenation by your physician of the disease is acceptable. This requirement takes effect for all incoming students for Fall 2010.
   
   
   
3. All Students must show proof of a tuberculosis (PPD) skin test Any baseline test is acceptable. It must be on file prior to entry. If you have/had a positive skin test, documentation of a negative chest x-ray and physician records must be provided.
   
   
   
4. All students living in any campus housing must show proof of having had the meningitis or menactra vaccine.
   
   
   

 

Any student who is not compliant, will have a hold placed on all future registration of classes until they submit the documentation.

Please do not delay.