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.

Please upload all of the below forms to your My Upstate Account. Contact the Office of Student Health if you have difficulty accessing these forms.

  • Student Health FormPDF 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 ExaminationPDF 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.
  • Immunizations
    Documentation of immunity is required. Complete age appropriate vaccination records must be provided. If insufficient record, then antibody titers are required.

    Proof of immunity to the following is required:
    - Measles
    - Mumps
    - Rubella
    - Varicella
    - Proof 3 Hepatitis B vaccinations or positive titer is required.

    Vaccination is required if insufficient vaccine record and negative or equivocal antibody titer.
    While antibody titers are not required by Upstate Medical University or NYSDOH if proof of well-documented record of age-appropriate vaccination, some external clinical sites within and outside of New York State may require antibody titers to participate in their clinical programs. You may submit evidence of these titers if you have copies of them. Any labs ordered will be the responsibility of the student.
  • Allergy History Screening FormPDF Icon
    This form is to be completed by the student.
  • Meningococcal Fact SheetPDF Icon
  • Meningococcal Vaccine Response FormPDF Icon
    Please read the informational sheet and complete the form.
  • Meningococcal Vaccine LetterPDF Icon
  • Release of Information Form for StudentsPDF Icon
  • Tuberculin Skin Test (PPD)
    A tuberculin skin test (PPD) can be completed prior to arriving on campus, or it will be placed at orientation. Documentation must include date placed, date read (within 48-72 hours of placement), induration in millimeters and signed by the interpreting healthcare provider. If you have had a positive PPD please provide documentation of the conversion date and induration, chest x-ray (within 12 months), and treatment taken (drug, date started and date completed).

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