Foster Johnson Health Center

Medical Forms & Policies

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Forms & Documents

• Affordable Care Act (ACA) & College Students Information
• Consent to Release Information Form
• Medical History Form
• Proof of Immunization Compliance Form
• Request for Immunization Exemption Form
• Statement of Exemption from COVID-19 SARS Immunization Form
• Tuberculosis Questionnaire Form

 

Policies

Medical Consent/Medical History

Complete the Student Information and Medical Consent sections of the Medical History Form. A Medical Consent form from you or parent/legal guardian (if you are a minor), is required to receive medical services at the health center.
 

Immunization/TB Questionnaire (Mandatory)

Louisiana Law (R.S. 17:170/R.S. 17:170.1/Schools of Higher Learning) requires that all students entering Grambling State University to be immunized for the following: Measles (2 doses), Mumps, Rubella--required for those born on or after January 1, 1957; Tetanus-Diphtheria (within the past 10 years); and against Meningococcal disease (Meningitis-2 doses).
For more information on meningitis, click the following link: https://www.cdc.gov/meningitis/index.html

The student health center is evaluating all entering students for exposure to tuberculosis (TB). Failure to return this questionnaire will result in you being placed on hold.

You will not be eligible to pay University fees until all immunization records are in compliance or the exemption is signed. If you waive immunizations, you may be required to leave school during a disease outbreak on campus. 
 

Consent to Release Information Policy

Students may request their medical records to be released in person, by mail, or by fax. Medical records are personal and private and cannot be released without your written permission, except as required by law. Please be prepared to provide a picture ID when requesting medical records and allow five business days to process the release of medical information. Consent to Release Information Form.