Health Forms

Different students have different requirements for which health forms need to be submitted. To help avoid confusion forms are organized according to student status. All forms are available as PDF files to be downloaded from the appropriate page. If you have any questions feel free to call the office at (413) 755-4230.

Click on the link below for forms and more information about medical records requirements.

  • Full-Time Students

    Full-time students, those here on a student visa, or if enrolled in a health program or Early Childhood Education are required to submit vaccination records (form listing requirements attached below).

    All full-time students or any students attending STCC on a student visa must submit the following vaccination records:

    • immunity to tetanus (vaccination within the last 10 years)
    • immunity to pertussis (single dose of pertussis containing vaccine after age 18)
    • immunity to measles (two live-vaccine doses or positive titer results)
    • immunity to mumps (two live-vaccine doses or positive titer results)
    • immunity to rubella (two live-vaccine doses or positive titer results)
    • immunity to hepatitis B (three vaccine doses or positive titer results)
    • immunity to chickenpox, known as varicella (two vaccine doses, positive titer results, or documented history of disease)

    PDF Form Health History Form: ViewDownload

    All students are asked to submit a Health History Form each year. This form lists medications, allergies, emergency contacts, etc.

    PDF Form Health Record Requirements: ViewDownload

    All Full-time students and students attendding STCC on a student visa must submit immunization records. This form lists the requirements.

  • Part-Time Students

    Most part-time students are not required to submit vaccination records. There are three exceptions: students enrolled in a health field, students enrolled in Early Childhood Education, and students attending STCC while on a student visa. These three groups of students must submit vaccination records to the college, all other part-time student need only submit the Health History Form. You may download the form below.

    PDF Form Health History Form: ViewDownload

    All students are asked to submit a Health History Form each year. This form lists medications, allergies, emergency contacts, etc.

  • STCC Employees

    All employees are asked to submit a Health History Form. This form lists medications, allergies, emergency contacts, etc.

    PDF Form Health History Staff Form: ViewDownload

  • Students in a Health Field

    Students enrolled in a health program or Early Childhood Education are required to submit vaccination records (form listing requirements attached below).

    All full-time students or any students attending STCC on a student visa must submit the following vaccination records:

    • immunity to tetanus (vaccination within the last 10 years)
    • immunity to pertussis (single dose of pertussis containing vaccine after age 18)
    • immunity to measles (two live-vaccine doses or positive titer results)
    • immunity to mumps (two live-vaccine doses or positive titer results)
    • immunity to rubella (two live-vaccine doses or positive titer results)
    • immunity to hepatitis B (three vaccine doses or positive titer results)
    • immunity to varicella (two live-vaccine doses or positive titer results, for these students history of disease is not sufficient)
    • tuberculosis screening
    • two Mantoux tests (PPD), the first within the past year, the second no more than a year previous to the first (2-step)
    • If the student has a history of a positive tuberculosis test, a Chest X-ray is required within the last 2 years and an annual tuberculosis questionnaire must be completed (attachment below)

    A physical exam (form attached below) is required from each student enrolled in a health field, Early Childhood Education, or who participates in athletics.

    PDF Form Health History Form: ViewDownload

    All students are asked to submit a Health History Form each year. This form lists medications, allergies, emergency contacts, etc.

    PDF Form Health Record Requirements: ViewDownload

    All students enrolled either in a health field or Early Childhood Education must submit immunization records. This form lists the requirements.

    PDF Form Student Physical Exam Form: ViewDownload

    All students enrolled either in a health field or Early Childhood Education must submit a record of a recent physical exam. This form is also for student athletes.

    PDF Form Tuberculosis Questionnaire: ViewDownload

    This form is for students that have a history of a positive tuberculosis test. This form must be submitted annually.

  • Student Athletes

    Student Athletes are required to submit vaccination records (form listing requirements attached below).

    Student Athletes must also submit the following vaccination records:

    • immunity to tetanus (vaccination within the last 10 years)
    • immunity to pertussis (single dose of pertussis containing vaccine after age 18)
    • immunity to measles (two live-vaccine doses or positive titer results)
    • immunity to mumps (two live-vaccine doses or positive titer results)
    • immunity to rubella (two live-vaccine doses or positive titer results)
    • immunity to hepatitis B (three vaccine doses or positive titer results)
    • immunity to chickenpox, known as varicella (two vaccine doses, positive titer results, or documented history of disease)

    PDF Form Health Record Requirements: View Download

    PDF Form Athletes must complete a one-time Sickle Cell Trait Form: View Download

    PDF Form Athletes must also complete an annual Athletic Preparticipation Evaluation: View Download