My Health Information

Immunization Requirements

For detailed information visit our Immunizations Page

Storrs Students:

Required Health Forms

Student Health Questionnaire

Student Health Questionnaire

  • Upload your official immunizations record OR Health History Form under ‘document upload’ and complete your Student Health Questionnaire on your Student Health Portal.
  • This form is required for all campuses EXCEPT:
    • Students at the School of Law – contact your school regarding immunization requirements
    • Students at the Medical, Dental or Graduate schools at UConn Health in Farmington – should contact your school for health history requirements as they may differ from those stated here
  • Deadlines: Your required immunization documentation and Student Health Questionnaire must be submitted prior to attending orientation. 
  • NOTE: Apple Preview should not be used to complete this PDF

 

 

    Consent for Treatment

    Consent for Treatment

    • For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order to receive treatment.

    Supplemental Health Forms

    Release of Health Information

    Authorization for Release of Health Information

    • To obtain a copy of your medical record from Student Health and Wellness please complete the Authorization for Release of Health Information Form. The form can then be faxed or emailed to address noted on the top of the form.

    Clinical and Field Placement Forms

    Clinical & Field Placement Student Health Record

    • In addition to the Student Health History Form, students on Clinical Rotations are required by practice sites to provide specific information about their current health and immunization status.
    • Students in clinical programs may have additional vaccine requirements beyond the university requirements. Additional details can be found at the Office of Clinical Placement Coordination.
    • Clinical Students requiring copies of their immunization record or lab test results, may access these records on their Student Health Portal under 'My Profile'

    Non-Responder Form

    • Non-Responder Form for Student Clinical Placement or Other Experiential Learning Experience.

        Immunization Exemption Form

        Immunization Exemption Form

        • If you require a medical exemption from the university’s immunization requirements please print, complete and upload this form to your student health portal. Please note that medical exemptions subjects you to exclusion from campus in the event of a vaccine-preventable disease outbreak. 
        • The university will only permit vaccination waivers for medical reasons. A signed statement indicating specific medical contraindication from your medical provider is required for medical exemption.

        Club Sports Form

        Club Sports Participant Clearance to Play Form

        • All Club Sports athletes will be required to fill out a Clearance to Play form. Participants must have the signature of their healthcare provider verifying they have had a physical examination within one year of the season’s start date.

        Department of Transportation (DOT) Medical Exam Form

        Department of Transportation (DOT) Medical Exam Form

        Two forms must be brought with you to your scheduled DOT Medical Exam:

        • Section 1 Driver Information of the DOT Medical Exam Form. This includes the Personal Information section and the Driver Health History section on pages 1 and 2. It is a fillable-PDF that can be filled out and printed. Then sign and date the driver certification statement. Failure to complete this form ahead of time and bring it with you will result in rescheduling of your appointment.
        • In addition to the Exam Form, please fill out and print the DOT Medical Certificate with the driver name, address and license info. The medical provider will complete their portion after your examination.

        Regional Campus Students:

        Required Health Forms

        Student Health Questionnaire

        Student Health Questionnaire

        • Upload your official immunizations record OR Health History Form under ‘document upload’ and complete your Student Health Questionnaire on your Student Health Portal.
        • This form is required for all campuses EXCEPT:
          • Students at the School of Law – contact your school regarding immunization requirements
          • Students at the Medical, Dental or Graduate schools at UConn Health in Farmington – should contact your school for health history requirements as they may differ from those stated here
        • Deadlines: Your required immunization documentation and Student Health Questionnaire must be submitted prior to attending orientation. 
        • NOTE: Apple Preview should not be used to complete this PDF

          Consent for Treatment

          Consent for Treatment

          • For students under 18 years of age, a parental or legal guardian authorization for medical treatment form must be on file in our office in order to receive treatment.

          Supplemental Health Forms

          Release of Health Information

          Authorization for Release of Health Information

          • To obtain a copy of your medical record from Student Health and Wellness please complete the Authorization for Release of Health Information Form. The form can then be faxed or emailed to address noted on the top of the form.

          Clinical and Field Placement Forms

          Clinical & Field Placement Student Health Record

          • In addition to the Student Health History Form, students on Clinical Rotations are required by practice sites to provide specific information about their current health and immunization status.
          • Students in clinical programs may have additional vaccine requirements beyond the university requirements. Additional details can be found at the Office of Clinical Placement Coordination.
          • Clinical Students requiring copies of their immunization record or lab test results, may access these records on their Student Health Portal under 'My Profile'

          Non-Responder Form

          • Non-Responder Form for Student Clinical Placement or Other Experiential Learning Experience.

              Immunization Exemption Form

              Immunization Exemption Form

              • If you require a medical exemption from the university’s immunization requirements please print, complete and upload this form to your student health portal. Please note that medical exemptions subjects you to exclusion from campus in the event of a vaccine-preventable disease outbreak. 
              • The university will only permit vaccination waivers for medical reasons. A signed statement indicating specific medical contraindication from your medical provider is required for medical exemption.

              Navigating the Student Health Portal

              Access your student health portal to:

              • Upload your required insurance cards or health history forms
              • View your immunization history
              • Complete pre-appointment or other required forms
              • Receive secure messages from your provider
              • Schedule an appointment with a healthcare provider
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              COVID-19 Medical Clearance to end Self-Isolation Form

              COVID-19 Medical Clearance to end Self-Isolation

              • The clearance to end self-isolation form must be completed and signed by a MD/DO/APRN and uploaded to your student health portal at myhealth.uconn.edu.