Visiting Students

Health History & Immunization Report Form

All visiting students are asked to complete and submit a Health History and Immunization Report form to the University Health Service. All immunization dates, history of disease, and serological evidence must be verified by the signature of a health practitioner; or as an immunization record submitted by a doctor's office, an institution, or school previously attended by the student. The signature of the certifying physician or school official must appear on the form.

Word document format: Health History and Immunization Report form
Acrobat reader format: Health History and Immunization Report form
All visiting students are required by New York State Law and University of Rochester University Health Service to provide documentation of the following: (Additional requirements for health profession students who will be at the University of Rochester for 8 or more weeks are located at the bottom of this page.)

Measles (Rubeola):
A student must demonstrate receipt of two doses of live measles vaccine¹ through one of the following ways:

The first dose given on or after the student's first birthday and the second on or after 15 months of age and at least 30 days after the first dose, OR
Serological evidence of immunity through a blood test performed by an approved medical laboratory, OR
Statement from the diagnosing physician that the student has had measles disease, OR
Proof of honorable discharge from the armed services within 10 years from the date of application to the institution. The proof of honorable discharge shall qualify as a certificate enabling the student to attend the institution pending actual receipt of immunization records from the armed services.
Mumps:
The student must submit evidence of a single dose of live mumps vaccine² through one of the following:

Single dose of live mumps vaccine given on or after the first birthday, OR
Serological evidence of mumps immunity through a blood test performed by an approved medical laboratory, OR
Statement from the diagnosing physician that the student has had mumps disease, OR
Proof of honorable discharge from the armed services within 10 years from the date of application to the institution.
Rubella:
The student must submit evidence of a single dose of live rubella virus vaccine² through one of the following:

Single dose of live rubella virus vaccine given on or after the first birthday, OR
Serological evidence of rubella antibodies through a blood test performed by an approved medical laboratory, OR
Proof of honorable discharge from the armed services within 10 years from the date of application to the institution.

MMR (measles/mumps/rubella) vaccine may be used to satisfy a single dose of measles/mumps/ rubella. Students born prior to January 1, 1957 need not provide proof of immunity for measles, mumps, and rubella; however, we ask that if they recall having had measles, mumps, or rubella to please note that on their form.

Meningococcus:
At this time, Meningococcus vaccination is not required. However, colleges and universities are now required by New York State law to distribute information about meningococcal meningitis (also called meningococcal disease) and vaccine availability to students. For information about meningococcal meningitis. You are asked to indicate your receipt of this information on the Health History Form and document vaccination date, if already received.

Tuberculin Skin Test (PPD):
For health profession students who will be at the University of Rochester less than 8 weeks: (Additional requirements for health profession students who will be at the University of Rochester for 8 or more weeks are located at the bottom of this page.)

A Mantoux intradermal skin test and interpretation is required within the last 12 months unless history of past positive skin test is reported. Tine tests are not acceptable. History of BCG alone does not meet the requirement. A chest x-ray report within the past 12 months is required only if the PPD is positive.

Additional Requirements

For all visiting health profession students who are at the University of Rochester for 8 weeks or more

Tuberculin Skin Test (PPD):
All visiting health profession students who will be at the University of Rochester for 8 weeks or more must provide documentation of TWO Mantoux intradermal skin tests (PPD) and interpretations. The first PPD must be received within one year of the second PPD, and the second PPD must be received within three months of the start of the appointment, unless history of past positive skin test is reported. Tine tests are not acceptable. History of BCG alone does not meet the requirement. A chest x-ray report within the past 12 months is required only if the PPD is positive.

For questions regarding immunization compliance, please contact Karen Bucci, Health Form Coordinator at 585-275-0697 (or toll-free at 888-363-2519 or hhf@uhs.rochester.edu).

Mandatory Health Fee & Health Insurance
All visiting health profession students who will be at the University of Rochester for 8 weeks or more must provide proof of health insurance, as well as pay a mandatory health fee of $10 per week for the number of weeks that they will be here at the University of Rochester. The health fee covers the charge for office visits to the University Health Service (UHS) and to the University Counseling Center (UCC). The fee does not cover the cost of diagnostic laboratory tests, medications, and other services that might be received during the office visit. These services may be covered by health insurance, depending on the student's coverage.

Word document format: Health plans for visiting students
Acrobat reader format: Health plans for visiting students
For questions regarding the mandatory health fee or covered services at the University Health Service, please call Laurie Strang at 585-275-2637.