VSU Health Evaluation Form

To all full-time students entering Virginia State University

All full-time students must provide documentation of a physical examination performed within the last twelve months and proof of immunization against diphtheria, tetanus, poliomyelitis, measles (rubeola), German measles (rubella) and mumps. In addition all full time students shall be vaccinated against meningococcal disease and hepatitis B unless the student or if the student is a minor, the student’s parent or legal guardian sign a written waiver stating he has received and reviewed detailed information on the risks associated with meningococcal disease and hepatitis B and the availability and effectiveness of any vaccine and has chosen not to or not have the student vaccinated. No full-time student is eligible to register for his second semester unless this information has been furnished and before the beginning of the second semester of 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 permitted to register for a second semester at Virginia State University.

  1. Proof of appropriate immunization is required for rubeola (measles, mumps, rubella, tetanus, diphtheria, polio and meningitis.
  2. Month, day and year must be documented of all vaccinations.
  3. 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.
  4. Immunization records will not be accepted with "white out" corrections, unsigned corrections, or notations in pencil.
  5. All immunization records must be signed by a physician or verified with an official stamp from a physician's office or health department.
  6. 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.
  7. 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.

Remember, the deadline for returning your completed health evaluation form is June 1st for the Fall term and December 1st for the Spring term. We recommend that students maintain copies of all forms.

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.

Health Evaluation Form

Download The Form

The Health Evaluation form is strictly for the use of the VSU Health Center and is required for all full-time students.

Health Evaluation Form