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 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.
  • 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.
  • Meningococcal Vaccine Letter PDF Icon
  • Release of Information Form for Students PDF Icon
  • Influenza Vaccination Requirement
    All students will be required to be vaccinated against influenza annually, by November 1st.  Flu shot clinics will be scheduled to facilitate this requirement.  Flu shots will also be available through Employee/Student Health during business hours. Proof of well documented immunization for the given flu season will be acceptable.