Health Services

Health Forms

Undergraduate Student Forms | Graduate Student Forms

Clark University Health Services
950 Main Street
Worcester, MA 01610
Telephone: 508–793–7467
Fax: 508–751–5947

Undergraduate Students (new incoming students only)

Please download, complete, and return your required health forms to the address below by July 1 for the fall semester and January 2 for the spring semester. Please note that all forms are PDFs.

1 Clark University Health Services PHYSICAL EXAMINATION FORM
Make an appointment with your Healthcare provider to have your physical completed.  We will accept physicals within the past 2 years. 

2 TB riskassessment ma-aug2018
This form must be reviewed and signed by your healthcare provider.  You must attach completed form with your health forms packet.  If risk factor(s) present, please complete required testing on the immunization record.

3 Undergraduate Immunization 2019
You should complete as many of your required vaccines as you can prior to your arrival. There will be immunization clinics scheduled when you arrive at the Clark University Health Service for those immunizations you may not have completed or that are not available in your country. Please note there is a charge for immunizations.

4 Meningococcal Info Waiver updated June 5 state seal 2018
Information about Meningococcal Disease, Meningococcal Vaccines, Vaccination Requirements and the Waiver for Students at Colleges and Residential Schools (May 2018)

5 Consent to Treat Minor
Complete only if your child is under 18 years old.

Director of Health Services
Clark University
950 Main Street
Worcester, MA 01610–1477

Please keep a copy of all of your forms for your records. Please do not email health forms to Health Services. Students should make arrangements for any needed immunizations with medical practitioners in their home country or state to avoid charges for immunizations and registration holds after arriving at Clark.

You will be notified via Clark email only if your health forms are incomplete. You are responsible for checking your Clark email regarding your forms compliance. Please do not call the Health Service if you have not returned your forms by the deadline.

 


Graduate Students (new incoming students only)

The State of Massachusetts requires that all students at any college within the state show a complete record of immunity against communicable disease. To ensure the best health for you and all Clark students, you will need to have your doctor or other health care provider complete the following Graduate Immunization Record forms:

1 TB riskassessment ma-aug2018
This form must be reviewed and signed by your healthcare provider. You must attach completed form with your health forms packet. If risk factor(s) present please complete required testing on the immunization record.

2 Graduate Immunization 2019
You should complete as many of your required vaccines as you can prior to your arrival. There will be immunization clinics scheduled when you arrive at the Clark University Health Service for those immunizations you may not have completed or that are not available in your country. Please note there is a charge for immunizations.

3 Meningococcal Info Waiver updated June 5 state seal 2018
Information about Meningococcal Disease, Meningococcal Vaccines, Vaccination Requirements and the Waiver for Students at Colleges and Residential Schools (May 2018)
 Complete only if age 21 years of age or under and did not receive meningococcal vaccine ACWY.

 


Accelerated Degree Program Students — Undergraduates students who enter a master's degree program after earning their B.A. as part of the Accelerated Degree Program must submit a new TB Risk Questionnaire and a Meningococcal waiver. Immunization files will be reviewed by the Health Services and students will be notified by e-mail if additional immunizations are needed.

TB riskassessment ma-aug2018
This form must be reviewed and signed by a healthcare provider and submitted to Health Services. If risk factor(s) present you will need required testing.
You may call Health Services for an appointment to have this form reviewed and signed by our healthcare provider. If risk factor(s) present you will need required testing which is available at our office.

Meningococcal Info Waiver updated June 5 state seal 2018
Information about Meningococcal Disease, Meningococcal Vaccines, Vaccination Requirements and the Waiver for Students at Colleges and Residential Schools (May 2018)
Complete only if age 21 years of age or under and did not receive meningococcal vaccine ACWY.

Your undergraduate immunization forms will be reviewed by Health Services. You will be notified by email if those requirements are not up to date.

 

All Graduate Students — Students should make arrangements for any needed immunizations with medical practitioners in their home country or state to avoid charges for immunizations and registration holds after arriving at Clark. Please contact Health Services  at healthservices@clarku.edu if you have questions.

Students must complete and upload the Graduate Immunization Record, TB Risk Questionnaire and Meningococcal Form. Completed forms should be uploaded to your online account as "immunization form" in your Applicant Status Page. All forms must be submitted by July 1 for fall enrollment and January 2nd for spring enrollment.

Please make sure to keep the original copies of all your forms and bring them with you when you arrive to Clark for orientation.

You will be notified via Clark email only if health forms are not complete. You are responsible for checking your Clark email regarding your forms compliance.