STATE UNIVERSITY OF NEW YORK STUDENT HEALTH INFORMATION
Overseas Academic Programs
Please type or print in ink.
Name:
Last First Middle
Program:
Location Abroad Approximate dates of the program Administering SUNY
To the Student: The information provided will remain confidential. Be aware that you will be responsible for your
own care, though SUNY and the organization hosting you overseas will try to provide assistance. Please be honest
with yourself and prepare accordingly. The questions that follow will help guide you in preparing for your stay
abroad. Indicating that you have health concerns may allow us to assist you in determining if you are prepared to
go and can receive appropriate treatment.
1. Do you have or have you had any physical, psychological or emotional conditions (including
eating disorders), that might require treatment abroad, or that might be exacerbated by the
stress caused by changes in culture, climate, diet or exercise? If yes, explain below and plan
to see your health care provider to discuss your care.
Yes
No
2. Have you arranged to receive all the necessary immunizations and medications
recommended for visiting the program site by reviewing information that:
- may have been provided by SUNY;
- may have been provided by the program site;
- is available on the US Center for Disease Control and Prevention website; and
- may be available from the government of the countries you will enter?
Yes
No
3. Do you have any allergies, reactions to medications, or dietary restrictions? If yes, consider
what you may need to manage your condition or restrictions. If needed, see your health
care provider for assistance in planning for your care. You may list any allergies or dietary
restrictions below so we can inform overseas providers. However, SUNY can only inform
and cannot ensure that you can be protected from exposure.
Yes
No
4. Are you currently taking or have you recently discontinued any medications you may need
while abroad? If yes, list medication name and purpose.
Please consider how you will have access to the medication you need and consult with your
physician to develop a plan for managing your condition while abroad. Depending on the
medication, SUNY may request additional information.
Yes
No
5. (Disclosure of disabilities is optional) Do you have a disability for which you are seeking
accommodations? If yes, provide a description of desired accommodations. Please be aware
that the Americans with Disabilities Act (ADA) does not apply outside the borders of the United
States. The Administering Campus will assist you, to the extent possible, to obtain the
accommodations you may want; however, it may not be able to obtain the accommodations
necessary to enable you to participate in all aspects of the overseas program.
Continued on next page.
Yes
No
Student Declaration
I grant the State University of New York, its employees, agents and overseas partners permission to share information
concerning my health condition with program representatives, my family, insurance company representatives and
with any physician, psychologist or counselor who treated me during the past five years or is now treating me. In
situations where I am unable to give oral or written consent, I grant permission for hospitalization and treatment
recommended and carried out under the supervision of a qualified physician, including administering anesthetics and
performing necessary surgery at my own expense. I appoint the representative of SUNY in the host country for the
program to act on my behalf in authorizing necessary medical, dental or surgical care, hospitalization or medical
evacuation for me should this be required.
I certify that all responses made on this form are true and accurate, and that I will notify the Administering Campus
hereafter of any relevant changes in my health that occur prior to the start of the program.
Student's Signature Date
Parent/Guardian’s Signature (required if student is under 18 years of age) Date
If you answered yes to 1, or 4, or no to 2 please make an appointment with your health care
provider to review your medical history and travel plans and have him/her sign below.
To the Treating Clinician: Please review the student’s medical history, discuss with him/her the upcoming
overseas study plans and sign below. A physical exam is not required by SUNY if you have adequate
information to advise the student.
I have reviewed this student’s medical history and examination with him/her, consulted with him/her about
vaccinations and medications that may be required, and developed a treatment plan for the student to manage his/her
condition during the overseas program, if needed. (Attach pages as necessary.)
Signature of Provider Printed Name of Provider
Address and Phone Number of Provider