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Dear New Student, Welcome to Sacred Heart University! (Sacred Heart University)

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Dear New Student,
Welcome to Sacred Heart University! We hope your experience here will be a healthy and happy one.
The State of Connecticut requires that we collect some basic health information before you begin your studies. All new students, unless you are
a distance learner (online classes only), must submit these forms. It is your responsibility alone to make sure that we have received all the
required information – failure to comply with the State requirements will result in your student account being blocked, prohibiting you from
registering for classes AND entry into university housing.
Please read the information below carefully and completely and follow all instructions. Feel free to call us with any questions or concerns at
203-371-7838 or email us at healthservices@sacredheart.edu.
A. Checklist: Please use this checklist to assist you in completing the New Student Health Form
Print out this form in its entirety.
Complete Sections I and IV (Personal Information and Tuberculosis High Risk Screening Questionnaire).
Bring the form to your healthcare provider and have them fill out Sections II, III, and V (Immunization History, Clinician Information, and TB
Screening Tests). The New Student Health Form must be signed, dated and stamped by your healthcare provider.
Scan or take a photo of the completed forms (and all supporting documents given to you by your healthcare provider).
Log in to your Student Health Portal (https://myhealth.sacredheart.edu) with your SHU username and password and follow all
instructions on the home page. You will be required to upload this form to the Portal. DO NOT MAIL, EMAIL OR FAX YOUR FORMS!
Await review and verification of your uploaded forms (up to 5 business days), then make sure to check your messages in the Student
Health Portal (“Messages” tab) or your SHU email and respond to any requests for further information or corrective action.
All health forms must be submitted by JULY 15
TH
FOR FALL SEMESTER (or 4 weeks prior to the start of classes for all other start dates)
B. Required Vaccinations/Screening
The following are required by the State of Connecticut and Sacred Heart University:
1. MMR (Measles, Mumps and Rubella) Vaccine: Two doses of each Measles, Mumps and Rubella vaccines (or the combined MMR
vaccine) administered at least 28 days apart with the first dose ON or AFTER your first birthday OR evidence of immunity to Measles,
Mumps and Rubella via blood titers – lab reports are required. Required for all students born after 1956.
2. Varicella (Chicken Pox) Vaccine: Two doses administered at least 28 days apart with the first dose ON or AFTER your first birthday OR
documentation of date of Varicella disease signed by your healthcare provider OR evidence of immunity to Varicella via blood titers –
lab reports are required. Required for all students born after 1979.
3. Meningitis ACYW Vaccine: One dose within the past 5 years only if you will be living in the residence halls.
4. Tuberculosis (TB) Screening Questionnaire: You must fill out this questionnaire and based on your answers, you may require skin or
blood TB testing.
For information on exemptions to the required vaccinations, please see the CT State Department of Public Health website section on
Immunization Laws and Regulations: https://portal.ct.gov/DPH/Immunizations/Immunization--Laws-and-Regulations.
C. Recommended Vaccinations
The following vaccines are recommended by Sacred Heart University, however you are not required to provide documentation that you have
received them: Hepatitis A, Hepatitis B, HPV, Meningitis B, and Tdap.
D. Programs Requiring Additional Health Forms
Some students are required to submit additional health forms for their specific program of study or sport. For instance, D1 athletes must submit
NCAA health forms to the Athletics Department, Nursing and some health science students must submit “CastleBranch” forms to their program,
and so on. Your program will notify you about any additional required health forms. Even if you have submitted health forms to your program
of study or to Athletics, you are still required to submit health forms to Student Health Services.
E. Minor Consent Form
If you will be under the age of 18 when you arrive on campus, you must have a parent or guardian fill out the “Minor Consent Form” and upload
it to your Student Health Portal in order for you to access Student Health Services. Please see the last page of this form.
SECTION I: PERSONAL INFORMATION To be filled out by student
PERMANENT HOME INFORMATION NOTIFY IN CASE OF EMERGENCY
Student’s Preferred E-mail Address Name Relationship
Student’s Cell Phone Home Phone Home Phone Cell/Work Phone
Home Address Address
O
–Sacred Heart University New Student Health Form (Page 1 of 3)
Submit all completed forms and any supporting documents by uploading to the Student Health Portal - https://myhealth.sacredheart.edu
Student Last Name
Student First Name
Student Middle Name
Date of Birth
SHU ID#
Date Beginning School: Fall 20_____ Spring 20_____ Commuter Campus Housing Undergraduate Graduate
MEDICAL & MENTAL HEALTH HISTORY: Check all that apply
Check if none apply to you
ADHD Cancer Eating Disorder rgan Transplant
Alcohol/drug abuse Cardiac condition/heart murmur High Blood Pressure Rheumatoid arthritis
Anxiety/Depression Concussion HIV/AIDS Seizure disorder
Asthma Crohn’s disease Immunocompromised Sickle cell anemia
Blood clotting/Bleeding disorder Diabetes Mononucleosis Thyroid Disorder
Other condition not listed (please list):
HOSPITALIZATIONS/SURGERIES: List dates and reasons
MEDICATIONS: List all prescriptions, over the counter medications and supplements Check if you do not take any medications
ALLERGIES: Drugs and other Severe Adverse Reactions: List all that apply and explain reaction Check if you have no allergies
Medication Allergies
Food Allergies
Other
If yes, please explain.
Do you carry an Epi Pen? Yes No
I confirm that the above information is accurate.
Student Signature
Date
Please continue to page 2
X
Gender Identity
Sex Assigned at Birth
MM / DD / YYYY MM / DD / YYYY
OPTION 1:
OR
Measles, Mumps, Rubella (MMR) Vaccination
Dose #1 Dose #2
OPTION 2:
OR
Measles Vaccination AND
Dose #1 Dose #2
MM / DD / YYYY MM / DD / YYYY
Mumps Vaccination AND
Dose #1 Dose #2
MM / DD / YYYY MM / DD / YYYY
Rubella Vaccination
Dose #1 Dose #2
MM / DD / YYYY MM / DD / YYYY
OPTION 3:
Measles Titer Result: Immune Not immune Date ______________ MM/DD/YYYY
Mumps Titer Result: Immune Not immune Date ______________ MM/DD/YYYY ATTACH ALL LAB REPORTS
Rubella Titer Result: Immune Not immune Date ______________ MM/DD/YYYY
*If not immune, you are required to get 2 MMR vaccines separated by at least 28 days
Dose #1 on or after first birthday, dose #2 at least 28 days later; Required if born after 1979.
MM/DD/YYYY
MM / DD / YYYY
Dose #2
YYY / YMM / DD
ears) y
MM / DD / YYYY
MM / DD / YYYY
HP
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
MM / DD / YYYY
–
VARICELLA VA
Sacred Heart University New Student Health Form (Page 2 of 3)
Submit all completed forms and any supporting documents by uploading to the Student Health Portal - https://myhealth.sacredheart.edu
Student Last Name:
Student First Name:
Date of Birth:
SECTION II: IMMUNIZATION HISTORY To be filled out by healthcare provider
MEASLES, MUMPS, RUBELLA (MMR) VACCINATION - Dose #1 on or after first birthday, dose #2 at least 28 days later; Required if born after 1956.
CCINATION -
OPTION 1:
OR
Varicella Vaccination
Dose #1
MM / DD / YYYY
Dose #2
MM / DD / YYYY
OPTION 2:
OR
Varicella Titer Result:
Immune Not immune Date ______________ MM/DD/YYYY ATTACH ALL LAB REPORTS
*If not immune, you are required to get 2 Varicella vaccines separated by at least 28 days
OPTION 3:
An incidence of disease will take the place of a vaccine
requirement
(Must be filled in by a physician/DO/APRN/PA)
Varicella (Chicken Pox) Disease
MENINGOCOCCAL VACCINATION
- Required of all students living in University housing
Meningococcal Vaccination
Date
Vaccination must have been given within 5 years of the first day of classes at SHU.
Must cover strains A, C, Y, W-135 MM / DD / YYYY
RECOMMENDED VACCINATIONS
HEPATITIS A
Dose #1
TETANUS, DIPHTHERIA,
PERTUSSIS
(within the last 10
Tdap
Td
Date
HEPATITIS B
Dose #1
Dose #2
MM / DD / YYYY
Dose #3
MM / DD / YYYY
HUMAN PAPILLOMAVIRUS (HPV)
V4
HPV9
Dose #1
MM / DD / YYYY
Dose #2
Dose #3
MENINGOCOCCAL SEROGROUP B
Trumenba
Bexsero
Dose #1
MM / DD / YYYY
Dose #2
Dose #3
SECTION III: CLINICIAN INFORMATION
To be filled out by healthcare provider
Date of Last Physical Exam: ____________________ Height: ____________________ Weight: _______________________ BP: _______________________
By signing below, I confirm that the above information is accurate to the best of my knowledge and that this student has no medical condition that
would prohibit him/her from participating fully in all educational activities. This is NOT a clearance for D1 or club sports.
Healthcare Provider Signature Date
Office Address and Phone #
Healthcare Provider Name and Title (print)
Office Stamp
Please continue to page 3
X
–
X
Sacred Heart University New Student Health Form (Page 3 of 3)
Submit all completed forms and any supporting documents by uploading to the Student Health Portal - https://myhealth.sacredheart.edu
Student Last Name:
Student First Name:
Date of Birth:
SECTION IV: TUBERCULOSIS HIGH RISK SCREENING QUESTIONNAIRE
TUBERCULOSIS (TB) RISK QUESTIONNAIRE Questions 1 through 4 to be answered by student
1. Have you ever had a positive tuberculosis (TB) skin or blood test in the past? Yes No
2. To the best of your knowledge, have you ever had close contact with anyone who was sick with TB? Yes No
3. Were you born in one of the countries listed below? If yes, which country? __________________________________ Yes No
4. Have you spent more than one month in one or more of the countries listed below? Yes No
IF you answered NO to all questions above, no further testing is required. Please sign below.
IF you answered YES to any question above, you must have a TB skin or blood test documented by your healthcare provider (see Step 1 below).
exemption for No
prior BCG. Please sign below.
Student Signature
Date
X
SECTION V: TB SCREENING TEST
TB screening test only required if student answers YES to any of the above questions. Healthcare provider must document test results and sign below.
All TB skin or blood tests and Chest X-ray (if required) must be done within 1 year prior to the start of school.
STEP 1: TB SKIN TEST (PPD)
OR
TB BLOOD TEST/IGRA STEP 2: CHEST X-RAY MEDICATION TREATMENT
Date PPD Planted: ____________
Quantiferon T-Spot
Date:_______________
Date PPD Read: ____________
Interpretation: NEG POS
Result: NEG POS
mm of induration: _________
*preferred with previous BCG
If test is Negative, no further testing.
If test is Positive, proceed to Step 2
Required if past or current positive TB skin or
blood test. Chest x-ray should be done within
one year of positive skin/blood test. Radiology
report must be included.
Chest X-ray Date:________________
Normal Abnormal
Medication(s):
Dates
Administered:
By signing below, I am certifying the accuracy of the information documented above.
Healthcare Provider Signature Date
Healthcare Provider Name and Title (print)
List of High Risk Tuberculosis Countries for TB Questionnaire above
Afghanistan Central African Republic Georgia Lithuania Palau Swaziland
Albania Chad Ghana Madagascar Panama Tajikistan
Algeria China Greenland Malawi Papua New Guinea Tanzania (United
Angola China, Hong Kong SAR Guam Malaysia Paraguay Republic of)
Anguilla China, Macao SAR Colombia Guatemala Maldives Peru Thailand
Argentina Comoros Guinea Mali Philippines Timor-Leste
Armenia Congo Guinea-Bissau Marshall Islands Portugal Togo
Azerbaijan Côte d'Ivoire Guyana Mauritania Qatar Tunisia
Bangladesh Democratic People's Haiti Mexico Republic of Korea Turkmenistan
Belarus Republic of the Congo Honduras Micronesia (Federated Republic of Moldova Tuvalu
Belize Democratic Republic India States of) Romania Uganda
Benin of Korea Indonesia Mongolia Russian Federation Ukraine
Bhutan Djibouti Iraq Morocco Rwanda Uruguay
Bolivia (Plurinational State of) Dominican Republic Kazakhstan Mozambique Sao Tome and Principe Uzbekistan
Bosnia and Herzegovina Ecuador Kenya Myanmar Senegal Vanuatu
Botswana El Salvador Kiribati Namibia Sierra Leone Venezuela (Bolivarian
Brazil Equatorial Guinea Kuwait Nauru Singapore Republic of)
Brunei Darussalam Eritrea Kyrgyzstan Nepal Solomon Islands Viet Nam
Bulgaria eSwatini Lao People's Democratic Nicaragua Somalia Yemen
Burkina Faso Ethiopia Republic Niger South Africa Zambia
Burundi Fiji Latvia Nigeria South Sudan Zimbabwe
Cabo Verde French Polynesia Lesotho Niue Sri Lanka
Cambodia Gabon Liberia Northern Mariana Islands Sudan
Cameroon Gambia Libya Pakistan Suriname
Source: WHO Global Health Observatory, Tuberculosis Incidence 2017. Countries with incidence rates of ≥20 cases per 100,000 population. For future updates, refer to http://www.who.int/tb/country/en/.
End of New Student Health Form
–Sacred Heart University Minor Consent Form
Submit completed form by uploading to the Student Health Portal - https://myhealth.sacredheart.edu. Click on the “Upload Documents” tab on the left
Student Last Name
Student First Name
Date of Birth
Student Health Services Minor Consent – Required only if student will be under age 18 at the start of classes
Consent for Treatment of a Minor:
I hereby grant permission to Sacred Heart University Student Health Services and its staff to provide my son/daughter (named above) with
appropriate medical care including treatment of illnesses/injuries, immunizations, prescription of medication, and any other treatments
that are medically advisable or appropriate in the opinion of the treating provider. I also grant permission to Student Health Services to
take such actions with respect to my son/daughter that are customary or appropriate in connection with his/her care, including
administering routine lab services such as blood counts, urinalysis, or ordering x-rays in the treatment of his/her condition. I understand
that in cases of emergency and/or when referral is necessary for major medical illnesses or injuries, Student Health Services will obtain my
consent through the telephone. I also understand that in such cases where Student Health Services has been unable to contact me, and in
the provider’s opinion a delay in initiation or provision of treatment would endanger the health or physical well-being of my son/daughter,
Student Health Services will render the necessary emergency medical care to my son/daughter without my consent.
Signature below indicates understanding of and agreement with the above information.
Parent/Guardian Signature: Date:
Parent/Guardian Name (print)
X
Relationship to Student
Phone #
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Completed 23 July 2020

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