CCSUConnected.
CONGRATULATIONS!
HEALTH FORMS VISIT WELLNESS SERVICES INFORMATION FROM STUDENT Central Pipeline Account Information LIVING ON CAMPUS
Please check the status of your required health information on-line: 1. Navigate to the CCSU home page at www.ccsu.edu. Point to CenralPipeline, then click for Students Save these dates to ensure you get theon fullCentralPipeline CCSU experience! Join us for an2. Open House where you can tour our campus, residence halls, From the CentralPipeline home page, click onvisit thethe WebCentral-Banner chat with current and explore ouraccount academic offerings. Aspassword. an Web tab andstudents login with your BlueNet username and accepted student, you are also welcome at our Accepted Students Day 3. From the Registration/Records tab, click on the Check Your Registration where you will have a chance to getregarding to know your learn more is Status link. Current information your professors, required documentation aboutfound your area of interest, and CLICK spend ON some timeHOLDS” with our Financial Aid here. NOTE: NOT “VIEW What will you gain byDO living on campus? counselors. Once you’ve submitted your confirmation deposit, register for will Select live in aTerm safe and supportive environment, learn skills that develop leadership You 4. (current semester) APPLYING AID one of our FOR Orientation Sessions where you will meet with an Academic potential, community service projects, have a for smoother To applybe forinvolved financialinaid, complete the Free Application Federaltransition Student into Aid Advisor, finalize your course schedule and spend some time getting to (FAFSA)get available www.ccsu.edu/finaid. To make sure the college, to class at in a matter of minutes, meet new friends, andFinancial have fun!Aid office know your future classmates! vaccination within five of the datename moving onto receives your information, list our school code “001378” and ouryears institution
COST & FINANCIAL AID
Welcome to CCSU RESLIFE!
ACCEPTED STUDENT CHECKLIST
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PAY ADMISSIONS DEPOSIT – FULL-TIME STUDENTS ONLY
campus (also known as the “Meningitis/Menactra
The payment of your Admissions Confirmation Deposit “Central Connecticut State University” on your form. Ready to Apply? Just follow these three easy steps... vaccine”). ($200) will confirm your intention to attend Central. Soon SPRING OPEN HOUSE April 25, 2020 The priority financial aid processing deadline for the fall semester is March 1 for after payment, receive registration information. STEP 1: Pay you thewill $200 admissions deposit. q SEND IN FINAL HIGH SCHOOL TRANSCRIPT For more information and to pay your deposit, visit www. new students. If you are currently enrolled in high school or another bursar.ccsu.edu or call or (860) 832-2010. STEP 2: Pay the $250 non-refundable housing deposit. institution, have your or institution CAMPUS TOURS Provided weekdaysyouatmust 10:00 amschool or 2:00 pm
forward a final official transcript indicating your date of Visit www.ccsu.edu/resIife/NewStudentLiving.html FOR FINANCIAL AID AND AID If you are not complete you will see a message q APPLY graduation to the Office ofthat Undergraduate SCHOLARSHIPS Saturday tours also available on: says, Admissions.
The first step in applying for financial is completing the
Failure to on have final transcripts sent financial may affect your generous financial aidYou packages based both merit and “Your medical records complete” Free Application for Federal Aidhousing (FAFSA). can STEP 3: offers Complete theStudent online application innot MyHousing. CCSU April 25 are registration and enrollment. find the application at fafsa.ed.gov. For more information, need. Each applicant is considered for a merit scholarship atred! the time of Missing information will be listed in visit Visit www.ccsu.edu/reslife/newStudentLiving.html www.ccsu.edu/finaid (Check www.ccsu.edu/visit for additional information) or call (860) 832-2200. PAY TUITION AND FEES q also be applied to qualifying acceptance. In addition, need-based aid may Your tuition bill is accessible through your Central APPLY FOR ON-CAMPUS RESIDENCE & DINING SERVICES once they have submitted the FAFSA (Free Application Federal q Atapplicants Pipeline account by loggingfor directly into who WebCentralCCSU Reslife, we have designed a process that enables all students to select After the Admissions ConfirmationDAYS Deposit has April been 18, 2020 ACCEPTED STUDENTS Banner Web. Once logged in, you can view your tuition Student Aid). Thison-campus could include grants, loans, and work-study. Finally,Health the CCSU Once your haswill been submitted to the paid, you may apply For more During they will livedocumentation withfor and wherehousing. they live! the month ofUniversity Mayoryou can pair Services, with bill, make credit card e-check payments, andaset up information and to apply, visit www.ccsu.edu/reslife/ Foundation also offers numerous endowed and merit scholarships to qualifying third-party payers who can make payments on your please allow 3-5 business days for processing. roommate/suitemates, and during the month of June your roommate pair or suitemate howtoapply or call (860) 832-1660. ORIENTATION behalf. The bill must be paid by the date posted on applicants. Find more information here: www.ccsu.edu/ccsufoundation/ your e-Bill Approved Financial Aidan awards, group can select into the available residence hall of your choice. Please your eyes Students admitted for the Fall 2020 semester willstatement. be invited tokeep attend BLUENET ACCOUNT q ACTIVATE endowedscholarships PLEASE KEEP A COPY OF YOUR DOCUMENTATION, INCLUDING scholarships, and sponsorships will be noted on the Your BlueNet Account givesfor youdetailed access to essential overnight orientation program duringYou thecan month of June. The on your CCSU email information. also check out our Room Selection account. Payments are due Julynew 15 for student the Fall semester technology resources andFAX allowsCONFIRMATIONS you to pay bills, receive
FOR YOUR RECORDS!
and about December 15 forprocesses. Spring semester. orientation willmore. have a student track, as well as a track specifically Guide on the Reslife website for information these important notices, and To begin the detailed activation ANNUAL COSTS
process, go totowards www.ccsu.edu and select the Central Beginning in March, the Office of New geared families/parents. Visit www.ccsu.edu/reslife/campusLiving/files/RoomSelectionGuide19-20NSFinal.pdf OBTAINServices BLUE CHIP STUDENT ID RESIDENT CONNECTICUT RESIDENT NEW ENGLAND RESIDENT OUT-OF-STATE General about University can be found at: qHealth Pipeline link at the information top of the page. From there, click on outYou will obtain your Blue Chip Student ID Card to when Student Programs will begin reaching to newly confirmed students Accounts Management. Tuition and Fees: http://web.ccsu.edu/healthservices/index.asp $11,068 Tuition and Fees: $13,360 Tuition and Fees: $23,124 advisor you visit campus to meet with your academic or For detailed information about living on$7,174* campus, please select their orientation date. during orientation. Your ID$7,174* card will give you access to Housing: $7,174* Housing: Housing: q COMPLETE HEALTH FORMS services. All matriculated students are required toMeal submitPlan: a visit our website www.ccsu.edu/ResLife, email us multiple at reslife@ccsu.edu, If$5,354* you have any questions or concerns please contact Meal Plan: $5,354* Food: $5,354*us at: medical form to Student Wellness Services. The form PERMIT or callbe usreturned at 860-832-1660. Total: $23,596 q OBTAIN PARKING Total: $35,652 sws@ccsu.edu should no later than July 15 Total: for the $25,888 Fall
www.ccsu.edu/accepted
A parking permit is required to park on campus. semester and December 15 for Spring semester. The All students are eligible to apply for a permit after form is included here or may be found on our website at registering for classes. Questions about parking permits www.ccsu.edu/health. *Costs based on standard double-occupancy, and standard meal plan. are subject can be directed toFees the Card Office at to change. Vaccination - The State of Connecticut mandates that all www.cardoffice.ccsu.edu. students living on campus receive the Meningococcal
Thank you.
ACCEPTED STUDENT CHECKLIST q
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PAY ADMISSIONS DEPOSIT – FULL-TIME STUDENTS ONLY The payment of your Admissions Confirmation Deposit ($200) will confirm your intention to attend Central. Soon after payment, you will receive registration information. For more information and to pay your deposit, visit www. bursar.ccsu.edu or call or (860) 832-2010. APPLY FOR FINANCIAL AID The first step in applying for financial is completing the Free Application for Federal Student Aid (FAFSA). You can find the application at fafsa.ed.gov. For more information, visit www.ccsu.edu/finaid or call (860) 832-2200.
vaccination within five years of the date moving onto campus (also known as the “Meningitis/Menactra vaccine”).
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APPLY FOR ON-CAMPUS RESIDENCE & DINING SERVICES After the Admissions Confirmation Deposit has been paid, you may apply for on-campus housing. For more information and to apply, visit www.ccsu.edu/reslife/ howtoapply or call (860) 832-1660. ACTIVATE BLUENET ACCOUNT Your BlueNet Account gives you access to essential technology resources and allows you to pay bills, receive important notices, and more. To begin the activation process, go to www.ccsu.edu and select the Central Pipeline link at the top of the page. From there, click on Accounts Management. COMPLETE HEALTH FORMS All matriculated students are required to submit a medical form to Student Wellness Services. The form should be returned no later than July 15 for the Fall semester and December 15 for Spring semester. The form is included here or may be found on our website at www.ccsu.edu/health. Vaccination - The State of Connecticut mandates that all students living on campus receive the Meningococcal
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SEND IN FINAL HIGH SCHOOL TRANSCRIPT If you are currently enrolled in high school or another institution, you must have your school or institution forward a final official transcript indicating your date of graduation to the Office of Undergraduate Admissions. Failure to have final transcripts sent may affect your registration and enrollment. PAY TUITION AND FEES Your tuition bill is accessible through your Central Pipeline account by logging directly into WebCentralBanner Web. Once logged in, you can view your tuition bill, make credit card or e-check payments, and set up third-party payers who can make payments on your behalf. The bill must be paid by the date posted on your e-Bill statement. Approved Financial Aid awards, scholarships, and sponsorships will be noted on the account. Payments are due July 15 for the Fall semester and December 15 for Spring semester. OBTAIN BLUE CHIP STUDENT ID You will obtain your Blue Chip Student ID Card when you visit campus to meet with your academic advisor or during orientation. Your ID card will give you access to multiple services. OBTAIN PARKING PERMIT A parking permit is required to park on campus. All students are eligible to apply for a permit after registering for classes. Questions about parking permits can be directed to the Card Office at www.cardoffice.ccsu.edu.
ACCOMMODATION SERVICES Campus Accessibility and Student Disability Services (SDS) Central Connecticut State University (CCSU) strives to ensure qualified students with disabilities equal access and reasonable accommodations, appropriate to their disability, throughout the campus environment including educational pursuits, programing and residential life. Students with documented disabilities including psychological, chronic health, physical, sensory loss, ADHD and/ or learning disabilities, should contact SDS to schedule a confidential Intake meeting to arrange reasonable accommodations. When to Contact SDS: Students should contact SDS after acceptance, and the decision made to attend CCSU. Students inquiring about campus access or requiring accommodations during campus tours, Accepted Student’s Day or Orientations should contact SDS to arrange special needs. Interpreting services must be requested at least 10 business days in advance of visit, to ensure services. Call or email SDS for request. Intake Meetings: A completed Intake form and documentation of a disability is required for approval of reasonable accommodations. Students with a diagnosed Learning Disability should provide a completed psychoeducational test should provide this testing. Students with psychological or other chronic physical health will need a diagnosis statement with functional limitations completed by a physician or clinician. See Intake form, Documentation Requirements and Verification form on SDS website. Students should contact the office with any questions about the above procedure or to discuss documentation requirements. Other Services: SDS provides assistive technology and weekly academic support meetings for registered students. CONTACT INFORMATION The Student Disability Services office is located in Willard-DiLoreto Hall, Room W 201. Email: DisabilityServices@ccsu.edu Phone: (860) 832-1952 www.ccsu.edu/SDS
CCSU strives to provide a fully accessible campus environment. In addition, qualified students with disabilities are provided the opportunity to request reasonable accommodations to ensure equal access under the law for their educational pursuits, programing and residential life. Students with questions or seeking accommodations should visit the Student Disability Services website for more information, call or email the office to arrange a confidential Intake meeting.
COST & FINANCIAL AID APPLYING FOR AID To apply for financial aid, complete the Free Application for Federal Student Aid (FAFSA), which is available at www.ccsu.edu/finaid. To make sure the Financial Aid office receives your information, use our school code “001378” and our institution name “Central Connecticut State University” on your form. The priority financial aid processing deadline for the fall semester is March 1 for new students.
SCHOLARSHIPS AND AID CCSU offers generous financial aid packages based on both merit and financial need. Each applicant is considered for a merit scholarship at the time of acceptance. In addition, need-based aid also may be applied to qualifying applicants once they have submitted the FAFSA (Free Application for Federal Student Aid). This could include grants, loans, and work-study. Finally, the CCSU Foundation also offers numerous endowed and merit scholarships to qualifying applicants. Find more information at www.ccsu.edu/ccsufoundation/endowedscholarships
ANNUAL COSTS CONNECTICUT RESIDENT Tuition and Fees: $11,068 Housing: $7,174* Meal Plan: $5,354* Total: $23,596
NEW ENGLAND RESIDENT Tuition and Fees: $13,360 Housing: $7,174* Meal Plan: $5,354* Total: $25,888
OUT-OF-STATE RESIDENT Tuition and Fees: $23,124 Housing: $7,174* Food: $5,354* Total: $35,652
*Costs based on standard double-occupancy and standard meal plan. Fees are subject to change.
COST & FINANCIAL AID The Office of Financial Aid at CCSU is ready to assist you in making your dream of acquiring a college education a reality. Our counselors are available Monday through Friday to answer questions about the financial aid application process and to help you fill out the paperwork. In addition to offering the lowest tuition for a fouryear degree in the state of Connecticut, CCSU offers numerous aid opportunities. Be sure to understand your options so you may take advantage of all CCSU has to offer.
NEED HELP? OFFICE OF FINANCIAL AID BURSAR’S OFFICE www.ccsu.edu/FINAID www.ccsu.edu/BURSAR Email: finaid@ccsu.edu Email: billing-bursar@ccsu.edu (860) 832-2200 (860) 832-2010
ADMISSIONS www.ccsu.edu/ADMISSIONS Email: admissions@ccsu.edu 860-832-2278
LIVING ON CAMPUS Welcome to CCSU RESLIFE! What will you gain by living on campus? You will live in a safe and supportive environment; learn leadership skills; participate in community service projects; enjoy a smoother transition into college life; get to class in a matter of minutes; meet new friends; and have fun! Ready to apply? Just follow these three easy steps... STEP 1: Pay the $200 admissions deposit. STEP 2: Pay the $250 non-refundable housing deposit.
Visit www.ccsu.edu/resIife/NewStudentLiving.html
STEP 3: Complete the online housing application in MyHousing.
Visit www.ccsu.edu/reslife/newStudentLiving.html
CCSU Reslife has designed a process that enables all students to select who they will live with and where they will live! During the month of May you can pair with a roommate/ suitemates, and in June your roommate pair or suitemate group can select the available residence hall of your choice. Please keep your eyes on your CCSU email for detailed information. You can also check out our Room Selection Guide on the Reslife website for detailed information about these processes. Visit www.ccsu.edu/reslife/campusLiving/files/RoomSelectionGuide19-20NSFinal.pdf For detailed information about living on campus, visit www.ccsu.edu/ResLife, email us at reslife@ccsu.edu, or call (860) 832-1660.
LIVING ON CAMPUS Residential Living Our nine residence halls offer a comfortable and safe place to live and learn. You’ll have access to free wi-fi, high-speed internet, cable TV, HBO GO, Showtime Anytime, fitness centers, game rooms, and study lounges. We offer three different styles of housing: quad style, suite style, and traditional. SUITE STYLE HOUSING: Two to four bedrooms per suite with a shared bathroom and living room. Mid-Campus Hall – Co-ed by suites. Two to three bedrooms share a bathroom and furnished living room. TV lounge and microwave area on each floor, computer lab, community kitchen, fireplace lounge, fitness center, multipurpose room, A/C, and laundry facilities. James Hall – Co-ed by suites. Three to four bedrooms share a bathroom and furnished living room. Kitchen and lounge on each floor, two computer labs, TV lounge, multipurpose room, A/C, and laundry facilities. James is a 21-plus building. If all students in a suite are 21 years of age, alcohol may be consumed. QUAD STYLE HOUSING: Three to five double rooms that share a bathroom. Gallaudet Hall – Co-ed by floor. Three rooms share a bathroom. Kitchens and lounge on each floor, computer lab, TV lounge, multipurpose room, A/C, and laundry facilities. Gallaudet is a 21-plus building. If all students in a suite are 21 years of age, alcohol may be consumed. Sheridan Hall - Co-ed by floor. Three rooms share a bathroom. Kitchen and lounge on each floor, computer lab, TV lounge, multipurpose room, A/C, and laundry facilities. Vance Hall - Co-ed by quad areas. Five rooms share a bathroom. Kitchen and lounge on each floor, computer lab, multipurpose room, and laundry facilities. Barrows Hall - All female residence hall focused on contemporary themes and programs related to women. Every three rooms share a bathroom. Kitchen on each floor, TV lounge, computer lab, study lounge, recreation room, and laundry facilities. TRADITIONAL HOUSING: Features rooms on each side of a hallway that share a large community bathroom. Sam May Hall – Co-ed by floor. One common bathroom on each floor, computer lab, large multipurpose/study space, kitchen, A/C, and laundry facilities. Beecher Hall – Co-ed by floor. One common bathroom on each floor, computer lab, large multipurpose/study space, kitchen, A/C, and laundry facilities. Seth North Hall – First-year residents only. Co-ed by floor. One common bathroom on each floor, computer lab, large multipurpose/study space, kitchen, and laundry facilities.
VISIT
Due to COVID-19, CCSU will not be hosting large campus events. However, we encourage you to sign up for an in-person campus tour, as we have implemented safety measures that allow guests and students to maintain a safe distance as we explore the campus. You may also join us for our virtual Open House to chat with current students, explore our academic offerings and speak with faculty and staff. As an accepted student, you are welcome at one of our virtual Accepted Students Day events where you will meet your professors, learn more about your major, and spend some time with our Financial Aid counselors. Finally, once you’ve submitted your confirmation deposit, register for one of our Orientation Sessions where you will meet with an Academic Advisor, finalize your course schedule and spend time getting to know your future classmates! Should our plans change as COVID-19 recommendations evolve, we will let you know! We look forward to seeing you soon!
VISIT Just two hours from Boston and New York and about an hour’s drive to the coast, our students enjoy numerous shopping and entertainment options as well as Long Island Sound beaches and beautiful coastal state parks. SHOPPING, DINING, & ENTERTAINMENT CCSU is 11 miles from Hartford, so our students have access to Connecticut’s capital city where they’ll find live entertainment at the XL Center; world-class theatre at the Hartford Stage and the historic Bushnell Theatre; and art exhibitions at the Wadsworth Atheneum Museum of Art and the New Britain Museum of American Art. Within walking distance, you’ll find Stop & Shop, Starbucks, Dunkin Donuts, drug stores, and local eateries featuring ethnic specialties like Japanese, Chinese, Mexican, Middle Eastern, and Italian foods. Only two miles from campus are Target and the West Farms Mall, which features more than 160 stores and restaurants, including Nordstrom, North Face, Apple, Champs, Sephora, and many other upscale and specialty stores. A short drive brings our students to West Hartford Center and Blue Back Square, a local hotspot with restaurants that include Bar Taco, Cheesecake Factory, and Bar Louis, plus shopping and the multi-screen Bow Tie Movie theatre. Also nearby you’ll find Guida’s Diary, a farmer-owned dairy cooperative operating since 1886; “Little Poland,” a bustling area in downtown New Britain with restaurants featuring Polish specialty foods, bakeries, and Polish-owned businesses; and the Hole in the Wall Theatre, New Britain’s own 40-year-old theatre presenting new and established works.
Many restaurants are within walking distance from campus and even more are a short drive away. Students can use their CCSU Blue Chip Card (campus ID and debit card account) at these area establishments: Big Cheese Pizza, Caribbean Food Concepts, Central Blue Moon Grill, Cheng’s Kitchen, Chili’s, D’Angelos, Domino’s Pizza, Dunkin Donuts, Elmer’s Place and Great Oaks Restaurant, Froyo World, Hot Harry’s Fresh Burritos, Mae Kong Thai Restaurant, Mooyah Burgers, New China, Nick’s Pizza, Panera Bread, Papa Johns, Pho Viet, Pizza Hut, Subway, Subway on Stanley, Sushi California, The Underground Deli, Tony’s Central Pizza, Wing It On, and Wings Over Newington. Across from campus, Stanley Park offers walking and running trails, tennis courts, soccer and baseball fields, and a skateboarding area. Stanley Golf Course, a public golf course and driving range, is less than a mile from campus. Nearby Mount Southington offers snowboarding and skiing with more than a dozen trails. Bowling and ice skating facilities are a short drive from campus. BANKING AND FINANCE On-campus banking is available to all CCSU students through Achieve Federal Credit Union, and New Britain offers branches of many financial establishments including Farmington Bank, Bank of America, Santander, Sovereign, People’s United, and Liberty Bank. ACCOMMODATIONS Courtyard by Marriott – Hartford/ Cromwell Courtyard by Marriott – Hartford/ Farmington Red Roof Inn – Newington Extended Stay America – Farmington
TRANSPORTATION Bus – CTfastrack opened in 2015 and transports CCSU students to Hartford and other areas of Connecticut on convenient, fast, and safe bus-only roadways and connector routes. In addition, the New Britain area is served by local buses for area travel as well as the Greyhound bus line with destinations around the country. Train – Amtrak service is conveniently available in Hartford with trains to Springfield, Boston, and beyond, and south to New York, Philadelphia, Washington, D.C., and the southeast. Air – Bradley International Airport, just a 30-minute drive from CCSU, offers travel from major carriers, including American, Delta, JetBlue, Southwest, United, Air Canada, Aer Lingus, and OneJet. HEALTHCARE The New Britain/Hartford area offers the best in healthcare in central and northern Connecticut with four major teaching hospitals just minutes from campus: Hospital of Central Connecticut, Hartford Hospital, St. Francis Hospital, and UConn Medical Center. For more information, go to www.ccsu.edu/visit.
HEALTH FORMS INFORMATION FROM STUDENT WELLNESS SERVICES Central Pipeline Account Information Please check the status of your required health information online. Here’s how: 1. Navigate to the CCSU home page at www.ccsu.edu. Click on Central Pipeline, then click on Central Pipeline for Students. 2. From the Central Pipeline home page, click on the WebCentral-Banner Web tab and log in with your BlueNet account username and password. 3. From the Registration/Records tab, click on Check Your Registration Status. Current information regarding your required documentation is found here. NOTE: DO NOT CLICK ON “VIEW HOLDS”
4. Select the current semester
STOP If your health information is not complete, you will see a message that says “Your medical records are not complete.” The information that is missing will be indicated in red. Once your documentation has been submitted to University Health Services, please allow three to five business days for processing. PLEASE KEEP A COPY OF YOUR DOCUMENTATION, INCLUDING FAX CONFIRMATIONS FOR YOUR RECORDS! General information about University Health Services can be found at http://web.ccsu.edu/healthservices/index.asp If you have any questions or concerns please contact us at sws@ccsu.edu
Thank you.
Connecticut State University Student Health Services Form Instructions Connecticut General Statute and CCSU requires the following information for all matriculated students (full and part time). Please submit this form to Student Wellness Services-University Health Services no later than August 15th (extended deadline) for the Fall semester and December 15th for the Spring semester.
Please email to sws@ccsu.edu as a PDF attachment only. Failure to submit the required form will result in a health hold on your student account. ***VERY IMPORTANT: Please note that if you send this form to your doctor they will only complete sections 1-5 and 7a-7d if applicable. It is your responsibility as an incoming student to complete all other areas of the form prior to submission. You may attach vaccination record from your physician office to the form as an alternative to your physician signing the form. Proof of immunity to Measles (Rubeola): you must provide proof of one of the following: Two measles or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive measles titer (blood test) Please submit a copy of the lab report results with health form. Proof of immunity to Rubella: you must provide proof of one of the following: Two rubella or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive rubella titer (blood test) Please submit a copy of the lab report results with health form. Proof of immunity to Mumps: you must provide proof of one of the following: Two mumps or two MMR immunizations (1st dose on or after your 1st birthday; second dose at least 28 days later); OR Lab results showing a positive mumps titer (blood work) Please submit copy of the lab report results with health form. Proof of immunity to Varicella (chicken pox): you must provide proof of one of the following: Two varicella immunizations (second dose at least 28 days after the first dose); OR Lab results showing a positive varicella titer (blood test) Please submit copy of the lab report results with health form. Proof of Meningococcal A,C, Y,W-135 vaccination (is required for all residential students prior to room assignment. No student may move into campus housing without proof of this vaccine. The vaccine must have been administered within five years before moving into the residential halls.
IMMUNIZATION EXEMPTIONS Students born prior to January 1, 1957 are exempt by age from the measles, mumps, and rubella requirement. Students born prior to January 1, 1980 are exempt by age from the varicella requirement.
Strongly Recommended Meningitis B: The Centers for Disease Control recommend students be immunized against Men B. Hepatitis B: The American College Health Association, the Connecticut Public Health Department, and the Centers for Disease Control recommend students be immunized against Hepatitis B Tetanus: A booster shot is recommended every ten years – Mandatory for Student Athletes Please check your Central Pipeline account no sooner than 7 business days after submitting the required information. Your Central Pipeline account will indicate the MISSING information under the “Registration Status” Section.
Important: Prior to submitting your information, please make a copy for your records. Please do NOT send multiple copies as this resets the processing time.
FOR OFFICE USE ONLY
Connecticut State University Student Health Services Form Semester Beginning School
Fall
Complete Missing: _______________________
Spring of __________
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Last Name
First Name
Date of Birth and Birthplace:
MI
Student ID #:
Sex/Gender:
Two doses for each Measles, Mumps, Rubella & Varicella One dose of Meningitis Complete TB Risk and/or Test or Treatment Vaccine & Date Given Requirements Incidence of OR Titer Test Results (attach lab report) OR Disease or MMR Date: Measles Titer Must be on or after 1st birthday. 1 Measles #1
2
3
Date Measles #2 Date: Mumps #1 Date: Mumps #2 Date: Rubella #1 Date: Rubella #2 Date:
Date :
or MMR or MMR
Neg
Date
Result Pos Mumps Titer Date:
Neg
Date
Pos Result Rubella Titer Date: Result Pos Varicella Titer Date:
Neg
or MMR or MMR or MMR
Must be on or after 1st birthday. Must be at least 28 days after 1st immunization. Must be on or after 1st birthday. Must be at least 28 days after 1st immunization.
Varicella is required only for students born on or after January 1, 1980 OR Incidence of OR #1 Must be on or after 1st birthday; Date: Chicken Pox Disease #2 Must be at least 28 days after 1st immunization Varicella #2 Date: Pos Neg Result Date: Provider Initials: Meningococcal (must include groups A, C, Y&W-135) If living on-campus, your most recent vaccination must be within 5 years of your 1st day of classes at the University. Please note: You will not be permitted to move in to campus housing without first providing Student Health Service with this information.
4 Varicella #1
5
Must be at least 28 days after 1st immunization.
Date(s):1._________2.__________ Brand of Vaccine: ______________________
I will not be living on-campus. I do not require this vaccine.
6 TUBERCULOSIS (TB) RISK QUESTIONNAIRE - A through D To be answered by the Student A. B. C. D.
Have you ever had a positive tuberculosis skin or blood test in the past? If you answer, “Yes,” Section 7b., “CHEST X-RAY”, must be completed To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? Were you born in one of the countries listed below? If yes circle country Have you traveled or lived for more than one month in one or more of the countries listed below? If yes circle country.
Yes Yes Yes Yes
No No No No
Afghanistan,Algeria,Angola,Anguilla,Argentina,Armenia,Azerbaijan,Bahrain,Bangladesh,Belarus,Belize,Benin,Bhutan,Bolivia,Bosnia&Herzegovina,Botswana,Brazil,Brunei,Darussalam,Bulgaria,BurkinaFaso,Burundi,Cambodia,Cameroon,C apeVerde,CentralAfricanRepublic,Chad,China,China:HongKongSpecialAdministrativeRegion,China:MacaoSpecialAdministrativeRegion,Colombia,Comoros,Congo,Côte d'Ivoire, Democratic People's Republic of Korea, Democratic Republic of the Congo,Djibouti,DominicanRepublic,Ecuador,ElSalvador,EquatorialGuinea,Eritrea,Estonia,Ethiopia,Fiji,FrenchPolynesia,Gabon,Gambia,Georgia,Ghana,Guam,Guatemala,Guinea,GuineaBissau,Guyana,Haiti,Honduras,India,Indonesia,Iraq,Iran,Japan,Kazakhstan,Kenya,Kiribati,Kuwait,Kyrgyzstan,LaoPeople'sDemocratic,Republic,Latvia,Lesotho,Liberia,Libyan,Arab,Jamahiriya,Lithuania,Madagascar,Malawi, Malaysia, Maldives, Mali, Marshall Islands,Mauritania,Mauritius,Mexico,Micronesia(FederatedStates),Mongolia,Morocco,Mozambique,Myanmar(Burma),Namibia,Nauru,Niue,Nepal,Netherlands,Antilles,NewCaledonia, Nicaragua,Niger,Nigeria,NorthernMarianaIslands,Pakistan,Palau,Panama,Papua,NewGuinea,Paraguay,Peru,Philippines,Poland,Portugal,Qatar,Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, Saint Vincent and the Grenadines, Sao Tome and Principe,Senegal,Serbia,Seychelles,SierraLeone,Singapore,SolomonIslands,Somalia,SouthAfrica,SouthSudan,SriLanka,Sudan,Suriname,Swaziland,Syrian,ArabRepublic,Tajikistan, Taiwan, Thailand, The former Yugoslav Republic of Macedonia,TimorLeste,Togo,Trinidad&Tobago,Turks&Caicos,Tunisia,Turkey,Turkmenistan,Tuvalu,Uganda,Ukraine,United Republic of Tanzania, Uruguay, Uzbekistan, Vanuatu, Venezuela(Bolivarian Republic),Viet Nam, Wallis and Futuna Islands, Yemen, Zambia ,Zimbabwe Based on WHO Global TB Report 2013
7. Prior BCG does not exempt patient from this requirement. If you answer NO to all questions no further action is required. If you answer YES to B-D of the above questions, Connecticut State University requires that a healthcare provider complete the following TB testing evaluation. 7a. TB BLOOD TEST
7a. TB SKIN TEST Use 5TU Mantoux test only.
Interferon-gamma release assay Date: Result:
NEG
POS
Date Planted: Date Read:
Interpretation (If no induration, mark 0) NEG POS _______mm of induration
7b. CHEST X-RAY Required within the past 12 months for a previous or current positive TB skin or blood test. Copy of X-ray report MUST be attached. X-ray is not needed if asymptomatic AND completed full course of treatment for the positive TB test (latent TB).
7c. TB TREATMENT
Chest X-ray Date: Result: Normal Abnormal (Attach copy of report)
Frequency: Start & Completion Dates:
MEDICATION (with dose):
Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended if not already completed) Hepatitis B #1 Date Last Tetanus Booster: Td
or Tdap
Hepatitis B #2 Date MEN B
Date:
I confirm that the information above is accurate. Clinician Signature:
Hepatitis B #3 Date MEN B
Hepatitis Titer Date MEN B
Result: POS
NEG
Signatures
Student consent for treatment required to be signed (If you are less than 18 years of age signatures of both the student and one
Date:
parent/guardian are required) I hereby grant permission for the Connecticut State University Health Services staff to provide me with appropriate medical and mental health treatment including medications for treatment of illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible for me to make such decisions. Furthermore, I understand that University Health Services
staff may disclose my student medical records and/or information from such records to appropriate University personnel and/or Emergency Contacts identified within my records in the event of a health or safety situation as determined by the Student Health Services staff.
Signature of Student
Signature of Parent/Guardian
Date:
Connecticut State University Student Health Services Form
Page 2 PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Student Name
Home/Personal Email Address
Permanent Home Information
Home Phone
Cell/Work Phone
Notify in Case of Emergency
Name
Street Address
Student Cell Phone
Home Phone
City
State
Zip
Cell/Work Phone
Street Address City
Name:
Relationship
Personal Physician/Healthcare Provider
State
Zip
Address: Telephone #:
FAX #
Personal Medical History- Please circle all below that apply to you. Check here if none apply
Alcohol/Substance Abuse Dental Problems Mononucleosis Anemia Diabetes Mumps Anxiety/Depression/Mental illness Gastrointestinal Conditions/IBS Rheumatic Fever Asthma Gynecological Conditions Seizures Cancer Hepatitis B or C Disease Sickle Cell Disease Cardiac Condition/Heart Murmur High Blood Pressure Thyroid Disorder Coagulation/Bleeding Disorder HIV/AIDS Tuberculosis Concussion Measles Other – please explain Allergies: Drugs & Other Severe Adverse Reactions - Please complete all that apply and explain reaction. Check here if you have no allergies
Medication
Food
Insect
Environmental
Seasonal
X-ray Contrast
Are any life threatening?
Yes
No
Do you carry an Epi Pen?
Yes
No
Prior Hospitalizations or Surgeries - Please list dates and reasons.
Medications – Frequent or regular- Please list all prescriptions, natural and over the counter medications.
Is there any other medical information or health concern that we should know about? Please attach any additional information to further explain your condition(s) or concern(s). Current Height**:
Current Weight**:
Last Blood Pressure (if known)**:
**not required
Did you make a copy for your records? Central Connecticut State University University Health Services 1615 Stanley Street New Britain, CT 06050 860/832-1925 Fax 860/832-2579
Eastern Connecticut State University University Health Services 185 Birch Street Willimantic, CT 06226
Southern Connecticut State University University Health Services 501 Crescent Street New Haven, CT 06515
Western Connecticut State University University Health Services 181White Street Danbury, CT 06810
CAMPUS CONTACTS Admissions (860) 832-CCSU (2278) admissions@ccsu.edu www.ccsu.edu/Admissions
Registrar (860) 832-2236 regstaff@ccsu.edu www.ccsu.edu/Registrar
Blue Chip Card Office (860) 832-2140 bennerj@ccsu.edu www.ccsu.edu/Bluechip
Residence Life (860) 832-1660 reslife@ccsu.edu www.ccsu.edu/ResLife
Bookstore (860) 832-2665 www.ccsu.edu/Bookstore
Student Affairs (860) 832-1601 taddeijaa@ccsu.edu www.ccsu.edu/StudentAffairs
Bursar (860) 832-2010 Billing-Bursar@ccsu.edu www.ccsu.edu/Bursar Financial Aid (860) 832-2200 finaid@ccsu.edu www.ccsu.edu/FinAid Information Technology (860) 832-1700 (Main) (860) 832-1720 (HELP Desk) techsupport@ccsu.edu www.ccsu.edu/IT Library, Elihu Burritt (860) 832-2060 (Main) (860) 832-2097 (Director) antonucci@ccsu.edu www.ccsu.edu/Library
Student Disability Services 860-832-1952; TTY: (860) 832-1954 DisabilityServices@ccsu.edu www.ccsu.edu/SDS Student Technology Center (Computer Lab) (860) 832-1720 techsupport@ccsu.edu www.ccsu.edu/STC Student Wellness Services 860-832-1926 Appointments 860-832-1925 General Inquiries www.ccsu.edu/SWS Veterans Affairs (860) 832-2838 VetAffairs@ccsu.edu www.ccsu.edu/Vets
Pre-Collegiate and Access Services (860) 832-1905 reasco@ccsu.edu www.ccsu.edu/PAS
Office of Recruitment & Admissions Central Connecticut State University PO Box 4010 New Britain, CT 06050-4010 Phone: 860.832.2278 Toll free (in CT): 888.733.2278