Incoming Graduate Students

Incoming Graduate Students

Welcome New Wildcats! Required Health Forms

You are required to complete the following forms before arriving on campus in the fall. The first four forms will assist us in creating your health record.

 

Complete Forms Now - Due February 1, 2015

If you have questions, please call (603) 862-4557.


Form  About  How to Complete and Submit  
 Health History 

This is an online form that will be available in mid-June. 

Your completed Physical Assessment and Immunization Records (see below) will be helpful when completing this form. 

If you are living with a chronic illness, you may submit additional health information to assist with continuity of care. 

COMPLETE ONLINE FORM

Physical Assessment (NOT REQUIRED)

A physical assessment is not required by Graduate students unless you are planning to particpate in athletics or club sports. If this is the case, you must print the form and have it completed and signed by your health care provider and mailed to UNH Health Services. 

 

DOWNLOAD/PRINT FORM

Mail completed form to...
UNH Health Services
Health Records and Administration
4 Pettee Brook Lane
Durham, NH 03824

You may also drop the form off at Health Services. If we are closed, there is a "drop box" on the front door.

Immunization Record

This is a form you must print and have completed and signed by your health care provider and mailed to UNH Health Services. 

Required and Recommended Immunizations:

  • MMR (Measles, Mumps and Rubella)
    MMR is the only immunization that the University requires.
    It is the University's policy that all students be adequately immunized against MMR prior to attendance. Students must submit proof of two MMR vaccinations or, if the vaccinations were received individually, proof of two Measles, two Mumps, and one Rubella vaccination. Students born before 1957 are exempt from providing documentation.
  • Meningococcal
    The American College Health Association (ACHA) recommends that college students consider vaccination to reduce their risk for potentially fatal meningococcal disease. In support of this recommendation, Health Services suggests you discuss the risk for meningococcal disease on campus with your medical clinician, and consider getting vaccinated. Ideally this would be done before coming to campus, but Health Services can provide the vaccine. An appointment can be scheduled with a Health Services nurse. Please note that vaccination against meningococcal disease is not a requirement for admission to UNH.
        
  • Letter from Medical Director about meningococcal disease
  • Hepatitis B
    We are strongly recommending that all students be vaccinated against Hepatitis B.

DOWNLOAD/PRINT FORM

Mail completed form to...
UNH Health Services
Health Records and Administration
4 Pettee Brook Lane
Durham, NH 03824

You may also drop the form off at Health Services. If we are closed, there is a "drop box" on the front door.

Tuberculosis Testing and Treatment

You must complete an online screening to determine your risk of Tuberculosis (TB). You will need your Blackboard username/password to complete the screening.

You will be asked to answer the following questions:

Were you born in a country with a high incidence of active Tuberculosis (TB) disease or have you… 

  • Been exposed to active TB disease, you are required to have your health care provider complete the “Tuberculosis Testing and Treatment” online form.
  • Had frequent or prolonged visits to a country with a high prevalence of TB disease?
  • Been a resident and/or employee of a high-risk congregate setting (e.g. correctional facility, long-term care facility, homeless shelter)?
  • Volunteered/worked with clients who are at increased risk for active TB disease?
  • Ever been a member of any a group that may have an increased incidence of latent M.tuberculosis infection or active TB? These groups include the medically underserved, low-income and abusers of drugs or alcohol.

If you answered “yes” to any of the above questions you are at increased risk for TB. You are required to print out the TB Testing and Treatment Form and bring it to your healthcare provider for further discussion and possible testing for TB. The form is available after you complete the online screening. It must be completed and submitted to Health Services prior to your arrival on campus, but only if you answered "yes" to any of the questions in the TB screening.

COMPLETE ONLINE TB SCREENING

Student Health Benefits Plan (SHBP) Enrollment/Waiver

This is an online process you must complete each year to indicate whether or not you will be enrolling in or waiving the Student Health Benefits Plan (SHBP).
 

The University of New Hampshire requires all full-time degree students to have adequate health insurance as a condition of enrollment. Proof of insurance is required at the beginning of every academic year. Students have the option of waiving the requirement if proof of adequate insurance through another plan is provided; or alternatively they can acquire affordable health coverage under a plan sponsored by the University and administered by Consolidated Health Plans Berkshire Hathaway Company. 

As part of this requirement, all full-time degree students must take some action - by either enrolling in the UNH Student Health Benefits Plan (SHBP), or completing a waiver with valid health insurance information.

Learn more about the Student Health Benefits Plan 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Confidentiality and Privacy at UNH Health Services

Health Services is committed to protecting the privacy and confidentiality of all patient/client health information. Our policies and procedures are in compliance with Federal and New Hampshire laws governing the safeguard of patient/client privacy. 

<p><br /><img src="/health-services/sites/unh.edu.health-services/files/media/PDF/EntranceRequirements/WelcomeUNH.jpg" alt="Welcome New Wildcats! " title="Welcome New Wildcats! " width="300" height="262" style="line-height: 19.185184478759766px; float: right; margin: 3px; border: 0px;" /><span style="color: #98ab52; font-family: Verdana, Geneva, sans-serif; font-size: 1.6em; font-weight: bold; line-height: 1.3em;">Required Health Forms</span></p>
<p><span style="line-height: 19px;">You are required to complete the following forms by July 1st. The first four forms will assist us in creating your health record.</span></p>
<ul>
<li><span style="line-height: 19px;"><a href="#Health_History">Health History</a></span></li>
<li><span style="line-height: 19px;"><a href="#Physical_Assessment">Physical Assessment</a></span></li>
<li><span style="line-height: 19px;"><a href="#Immunization_Record">Immunization Record</a></span></li>
<li><span style="line-height: 19px;"><a href="#TB">Tuberculosis (TB) Screening&nbsp;</a></span></li>
<li><a href="#SHBP">Student Health Benefits Plan Enrollment or Waiver&nbsp;</a></li>
<li><span style="line-height: 19px;"><a href="#Permission_17">Permission to Treat Student/Patient (only for students who are age 17 or under)</a></span><span style="line-height: 1.5em; font-size: 0.8em;">&nbsp;</span></li>
</ul>
<address></address>
<h2>Complete Forms Now - <span style="text-decoration: underline;">DUE JULY 1, 2013</span></h2>
<p><span style="line-height: 19.185184478759766px; white-space: pre;">This website will walk you through the process of completing the forms. <br />If you have questions, please call (603) 862-4557 or stop by the Health Services table at the Orientation Resource Fair.  </span></p>
<table style="border: 3px solid #4b5750; width: 700px; height: 3px;" border="3" cellspacing="10" cellpadding="10" align="left">
<tbody>
<tr>
<td style="text-align: center;"><strong>Form</strong></td>
<td style="text-align: center;"><strong>&nbsp;About&nbsp;</strong></td>
<td style="text-align: center;"><strong>How to Complete and Submit &nbsp;</strong></td>
</tr>
<tr>
<td><strong>&nbsp;<a name="Health_History"></a>Health History&nbsp;</strong></td>
<td>
<p><strong>This is an online form that will be available in mid-June.&nbsp;</strong></p>
<p>Your completed Physical Assessment and Immunization Records (see below) will be helpful when completing this form.&nbsp;</p>
<p>If you are living with a chronic illness, you may submit additional health information to assist with continuity of care.&nbsp;</p>
</td>
<td><strong>ONLINE - COMING SOON.&nbsp;</strong></td>
</tr>
<tr>
<td><strong><a name="Physical_Assessment"></a>Physical Assessment</strong></td>
<td>
<p><strong>This is a form you must print and have completed and signed by your health care provider and mailed to UNH Health Services.&nbsp;</strong></p>
<p>First year students are required to have a physical exam upon entrance into the University. We understand that some students may have had a physical exam within the year and insurance companies will not pay for a second exam. If this is the case, please have your health care provider complete the Physical Assessment form with the date and information from your recent exam. If you do not have a current physical or physical appointment scheduled before the July 1st due date, late submissions will be accepted. Students intending to play a sport should contact their coach for specific physical date requirements.</p>
</td>
<td><a href="https://www.unh.edu/health-services/sites/unh.edu.health-services/files/media/PDF/PhysicalExamForm2013.pdf"><strong><span style="line-height: 1.5em;">DOWNLOAD/PRINT FORM</span></strong>
</a>
<p><strong>Mail completed form to...</strong><br />UNH Health Services<br />Health Records and Administration <br />4 Pettee Brook Lane<br />Durham, NH 03824</p>
<p>You may also drop the form off at Health Services. If we are closed, there is a "drop box" on the front door.</p>
</td>
</tr>
<tr>
<td><strong><a name="Immunization_Record"></a>Immunization Record</strong></td>
<td>
<p><strong>This is a form you must print and have completed and signed by your health care provider and mailed to UNH Health Services.&nbsp;</strong></p>
<p><strong>Required and Recommended Immunizations:</strong></p>
<ul>
<li><span style="line-height: 1.5em;"><strong><a href="http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-mmr.pdf">MMR (Measles, Mumps and Rubella) </a><br />MMR is the only immunization that the University requires. </strong>It is the University's policy that all students be adequately immunized against MMR prior to attendance. Students must submit proof of two MMR vaccinations or, if the vaccinations were received individually, proof of two Measles, two Mumps, and one Rubella vaccination. Students born before 1957 are exempt from providing documentation.</span></li>
<li><span style="line-height: 1.5em;"><strong><a href="http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-mening.pdf">Meningococcal</a></strong><br /> The American College Health Association (ACHA) recommends that college students consider vaccination to reduce their risk for potentially fatal meningococcal disease. In support of this recommendation, Health Services suggests you discuss the risk for meningococcal disease on campus with your medical clinician, and consider getting vaccinated. Ideally this would be done before coming to campus, but Health Services can provide the vaccine. An appointment can be scheduled with a Health Services nurse. Please note that vaccination against meningococcal disease is not a requirement for admission to UNH.</span>&nbsp; &nbsp;&nbsp;</li>
<li><a href="http://unh.edu/health-services/services/recommended-immunizations" style="line-height: 1.5em;">Letter from Medical Director about meningococcal disease</a></li>
<li><a href="http://unh.edu/health-services/services/faq-meningococcal-disease" style="line-height: 1.5em;">FAQ meningococcal disease</a></li>
</ul>
<ul>
<li><span style="line-height: 1.5em;"><strong><a href="http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-b.pdf" target="_blank">Hepatitis B</a></strong><br /> We are strongly recommending that all students be vaccinated against Hepatitis B.</span></li>
</ul>
</td>
<td>
<p><span style="line-height: 1.5em;"><strong><a href="/health-services/sites/unh.edu.health-services/files/media/PDF/EntranceRequirements/immunizationRecord2013.pdf" target="_blank">DOWNLOAD/PRINT FORM</a></strong></span></p>
<p><strong>Mail completed form to...</strong><br />UNH Health Services<br />Health Records and Administration <br />4 Pettee Brook Lane<br />Durham, NH 03824</p>
<p>You may also drop the form off at Health Services. If we are closed, there is a "drop box" on the front door.</p>
</td>
</tr>
<tr>
<td><strong><a name="TB"></a>Tuberculosis Testing and Treatment</strong></td>
<td>
<p><strong>This is an online screening form that will be available in mid-June. &nbsp;You will be asked to answer the following questions:</strong></p>
<p>Were you born in a country with a high incidence of active Tuberculosis (TB) disease or have you…<span style="line-height: 1.5em;">&nbsp;</span></p>
<p>Have you…</p>
<ul>
<li><span style="line-height: 1.5em;">Been exposed to active TB disease, you are required to have your health care provider complete the “Tuberculosis Testing and Treatment” online form.</span></li>
<li><span style="line-height: 1.5em;">Had frequent or prolonged visits to a country with a high prevalence of TB disease?</span></li>
<li><span style="line-height: 1.5em;">Been a resident and/or employee of a high-risk congregate setting (e.g. correctional facility, long-term care facility, homeless shelter)?</span></li>
<li><span style="line-height: 1.5em;">Volunteered/worked with clients who are at increased risk for active TB disease?</span></li>
<li><span style="line-height: 1.5em;">Ever been a member of any a group that may have an increased incidence of latent M.tuberculosis infection or active TB? These groups include the medically underserved, low-income and abusers of drugs or alcohol.</span></li>
</ul>
<p>If you answered “yes” to any of the above questions you are at increased risk for TB. You are required to print out the TB Testing and Treatment Form and bring it to your healthcare provider for further discussion and possible testing for TB.</p>
<p>The completed form must be submitted to Health Services prior to your arrival on campus.</p>
</td>
<td><strong>ONLINE - COMING SOON.&nbsp;</strong></td>
</tr>
<tr>
<td><strong><a name="SHBP"></a>Student Health Benefits Plan (SHBP) Enrollment/Waiver</strong></td>
<td>
<p><span style="line-height: 1.5em;"><strong>This is an online form you must complete to indicate whether or not you will be enrolling in or waiving the Student Health Benefits Plan (SHBP).</strong></span><br />
<span style="line-height: 1.5em;">&nbsp;</span></p>
<p><span style="line-height: 1.5em;">The University of New Hampshire requires all full-time degree students to have adequate health insurance as a condition of enrollment. Proof of insurance is required at the beginning of every academic year. Students have the option of waiving the requirement if proof of adequate insurance through another plan is provided; or alternatively they can acquire affordable health coverage under a plan sponsored by the University and administered by Health Plans, Inc., a subsidiary of Harvard Pilgrim Health Care.</span><br /><span style="line-height: 1.5em;">&nbsp;</span></p>
<p><span style="line-height: 1.5em;">As part of this requirement, all full-time degree students must take some action - by either enrolling in the UNH Student Health Benefits Plan (SHBP), or requesting a waiver.</span></p>
<ul>
</ul>
</td>
<td><strong><a href="http://unh.edu/health-services/shbp">Learn more about the Student Health Benefits Plan</a>&nbsp;</strong></td>
</tr>
<tr>
<td>
<p><strong><a name="Permission_17"></a>Permission to Treat Underage Student/Patient </strong></p>
<p><strong>ONLY FOR STUDENTS WHO ARE 17 OR UNDER</strong></p>
</td>
<td>
<p><strong>This form needs to be printed, completed and signed by the parent/legal guardian of students w<span style="text-decoration: underline;">ho are age 17 and under</span>. The completed form should be mailed to Health Services.</strong></p>
<p>&nbsp;</p>
</td>
<td>
<p><a href="http://www.unh.edu/health-services/sites/unh.edu.health-services/files/media/PDF/EntranceRequirements/205.1Consent4TxMinor.pdf" target="_blank"><strong>DOWNLOAD/PRINT FORM&nbsp;</strong></a></p>
p><strong>Mail completed form to...</strong><br />UNH Health Services<br />Health Records and Administration <br />4 Pettee Brook Lane<br />Durham, NH 03824</p>
<p>You may also drop the form off at Health Services. If we are closed, there is a "drop box" on the front door.</p>
<p><span style="line-height: 1.5em;">HealthServicesHealthServicesHealth &nbsp;</span></p>
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<h2><a href="http://unh.edu/health-services/confidentiality">Confidentiality and Privacy at UNH Health Services</a></h2>
<p style="font-size: 12px;">Health Services is committed to protecting the privacy and confidentiality of all patient/client health information. Our policies and procedures are in compliance with Federal and New Hampshire laws governing the safeguard of patient/client privacy.&nbsp;</p>