A completed Health History form is required by RWC for entrance and attendance. The Health History form is distributed to each new student prior to arrival on campus, at RWConnections by Admissions and is also locate on the RWC Website. With HIPPA compliance, all information is kept in confidential files located in the Health Center.
To download this four-page form, please visit the link shown below. To ensure confidentiality, please submit the Health History form directly to the Health Center via mail, email or fax to (585) 594-6920.
If you have any questions, please feel free to contact the Health Center at (585) 594-6360.
TRADITIONAL UNDERGRADUATE HEALTH FORM:
The Health History form is required to be completed and sigend by student or parent(s), and medical provider to be approved by NSY Law 2165 & 2167 standards.
Health History Form
An up-to-date immunization record from a previous school or physician may be submitted to fulfill the requirements of page 4.
If the meningococcal meningitis vaccine is declined (see page 2 of the Health History form), the appropriate line
must be signed and dated by the student.
Part-time, non-traditional and graduate students taking six or more credits per semester are required to complete and submit the RWC Immunization form.
Part-time, non-traditional, and graduate students, however, do not need to submit proof of a physical or complete a health history record. Each program or division will distribute the appropriate immunization form to the prospective student at the time of acceptance into the program.
A generic immunization form may be downloaded by clicking
Part-Time, Non-Traditional, and Graduate Immunizations Form
Measles, Mumps, Rubella (MMR)
All college students born after 1956 need two doses of MMR given at least 28 days apart. The first dose is usually administered after the first birth date, and the second dose is generally given between the ages of four to six. Serologic evidence of immunity (positive titer tests for measles, mumps, and rubella) is acceptable as long as a copy of the lab results is submitted to the Health Center.
Proof in the form of an official copy of immunization dates from a doctor or previous school must be on file in the Health Center within 30 days of the start of the first class. (See page 4 of the health history form.)
Exceptions
A student may be exempt from either or all of the required immunizations for medical or religious reasons. Certified documentation must be submitted to the Health Center.
• Students who were born prior to January 1, 1957, are exempt from the MMR requirement.
• The law does not apply to students enrolled for fewer than six semester hours.
• Proof of honorable discharge from the armed services within ten years from the date of application to RWC qualifies as a certificate enabling a student to attend classes pending actual receipt of immunization records from the armed services.
Tuberculosis Screening (TB)
This is not a vaccine. The purpose of the TB screening is to identify persons with TB infection (active TB) or latent TB infection (LTBI). Both forms of TB required treatment.
The ACHA (American College Health Association) and other professional organizations now propose that only HIGH RISK individuals be tested.
Following high risk groups:
1. Persons with signs or symptoms of active TB
2. Persons with HIV infection
3. Persons who have been close contacts of a person with
infectious TB
4. Persons who have resided in, have been employed, or
volunteered at nursing homes, health care facilities, jails
and prisons, homeless shelters, residential facilities for
patients with (AIDS)
5. Persons who have lived, within the past 5 years, in
countries where TB is an endemic.
Proof of a TB screening - only PPD (Mantoux) tests are acceptable. Both the placement date and the read date (which must be within two to three days) must be indicated. A positive TB test will require a chest x-ray and evaluation for medication. Additionally, nursing majors are required to get annual PPD tests.
Meningococcal Meningitis Vaccine
NYS requires all colleges and universities to distribute information regarding meningococcal meningitis disease along with vaccination information, which is included with the health history form or may be downloaded by clicking here.
Although this vaccine is not required for college attendance in NYS, it is highly recommended.
NOTE: If the meningococcal meningitis vaccine is declined (see page 2 of the health history form), the appropriate section must be signed and dated by the student.
Tetanus/Diphtheria Booster
Most recent Td booster must be within past 10 years.
Hepatitis B
Students enrolled in the Nursing program are required to provide evidence of Hepatitis B immunity.
