New 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 the Student Health Portal using your MyAccounts ID and password.

• Student Health Form
  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
  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 of 3 Hepatitis B vaccinations or positive titer is required.
- COVID-19 Vaccine series

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 is available, 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. Fee for any titers ordered will be the responsibility of the student or billed through their health insurance provider.

• Allergy History Screening Form
  This form is to be completed by the student.
• Meningococcal Vaccine Response Form
  Please read the informational sheet and complete the form.
• Meningococcal Vaccine Letter
• Release of Information Form for Students
• 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).