Health Evaluation Form
To all full-time students entering Virginia State University:
The state of Virginia law requires that all full-time students who are enrolling for the first time in a four-year public institution provide to the University a health history and an official immunization record. Virginia State University further requires that each full-time student provide documentation of a physical examination performed within twelve months preceding his/her initial enrollment. Previously enrolled students who are returning as full-time students after an absence from campus greater than one year must submit a new history and physical examination.
The Health Evaluation Form contains four parts, one section to be completed by you and three sections to be completed by your licensed health care provider. You are responsible for returning your COMPLETED health evaluation form directly to the department of Student Health Services. ALL information must be on this form. Students who do not provide all required information will not be allowed to occupy a dormitory room and will not be permitted to register for a second semester at Virginia State University.
Information about your immunization records:
Proof of appropriate immunization is required for rubeola (measles, mumps, rubella, tetanus, diphtheria, polio and meningitis.
Month, day and year must be documented of all vaccinations.
Persons born before 1957 are considered immune to rubeola and mumps. However, proof of appropriate immunization must be provided for the remainder of the diseases mentioned above.
Immunization records will not be accepted with "white out" corrections, unsigned corrections, or notations in pencil.
All immunization records must be signed by a physician or verified with an official stamp from a physician's office or health department.
If an official documentation of the appropriate vaccination is not available it will be necessary to repeat the vaccination (s). Laboratory evidence of immunity to rubella and rubeola is acceptable.
If you must request immunization records from sources other than your own physician's office, you are responsible for making sure that these records are received by Student Health Services.
If you have any questions please do not hesitate to call the office of Student Health Service between the hours of 8:00 a.m. - 5:00 p.m., Monday - Friday at (804) 524-5711 or (804) 524-6833.