New Upstate Students - Mandatory Health Clearance Forms

Listed below are the health forms that need to be completed to meet the requirements for registration.

In an effort to facilitate your health clearance at future clinical sites and to fulfill the requirements of the New York State Department of Health Code, these forms must be completed and kept on file in the Employee/Student Health office.

Your record will be viewed by the Student Health personnel, and if necessary, referred to the Medical Director for further evaluation prior to clearance.

Contact the Office of Student Health if you have difficulty accessing these forms.
  • Student Health Form PDF Icon
    This form is to be completed by the student with each item being checked and an explanation for all "yes" answers in the space provided. You may use an additional sheet, if necessary. Your health care provider needs to complete the summary section, sign and date.
  • Record of Medical Examination PDF Icon
    Completion of this form requires a physical examination within 6 months prior to beginning classes. All sections of this form are to be completed by your health care provider, with each item marked individually (no lines through will be accepted). The forms must be signed, dated and stamped by your health care provider and include address and phone number.
  • Student Immunization Form PDF Icon
    All sections need to be completed by your health care provider. Laboratory testing for antibody titers is required and copies of the laboratory report must be returned with the form. Dates of immunization alone are not acceptable.

    Please note: Tuberculin skin test should not be done. This will be placed, on campus, before registration.
  • Allergy History Screening Form PDF Icon
    This form is to be completed by the student.
  • Meningococcal Fact Sheet PDF Icon
  • Meningococcal Vaccine Response Form PDF Icon
    Please read the informational sheet and complete the form.
  • Release of Information Form for Students PDF Icon