Forms

Incoming Students

Health Status Form Packet 2020-21 (To be completed by incoming freshmen and transfer students only) – Due June 24, 2020

If you are missing or need duplicates of certain portions of the HSR Packet, the individual links are below:

  1. Face Sheet
  2. Medical History
  3. Physical
  4. Immunizations
  5. Tuberculosis Risk Assessment

Immunization Waivers

General Forms

Notice of Privacy Practices
Housing Accommodation Form
Authorization: Disclosure of Health Care Information
Completed authorization form can be:
– Mailed to: Winslow Health Center, 520 N Main St, Box 26, Meadville, PA 16335
– Faxed to: (814) 336-3050
– Emailed to: whc@allegheny.edu
Requests will be completed within 30 days. In pursuant to PA Code 563.6., we are required to keep records for seven years, however, WHC’s current policy is to maintain alumni health records for ten years post graduation or withdrawal from Allegheny (subject to change without notice).

Instructions

Incoming Students

All students who matriculate at Allegheny College are required to complete the Health Status Report. Completion of this requirement is universal for each student entering Allegheny College as a freshman or transfer. This information is designed to safeguard the health and well-being of our student body. The Health Status Report is a 5-part document that includes the following forms:

  • Consent Form / Face Sheet
  • Report of Medical History
  • Report of Physical Examination (Must be within 12 months of your arrival.)
  • Immunization Report
  • Tuberculosis Risk Assessment

Instructions for students:
Complete your portion of the Consent and Report of Medical History forms. Your health care provider is responsible for signing the Medical History, Physical Examination, Immunization, and TB Risk Assessment forms. Please schedule an appointment with your Primary Care Provider (PCP) at your earliest opportunity in order to complete your Health Status Form by the July 1 (for fall semester) or December 1 (for spring semester) deadline. Questions regarding completion of the Health Status Form can be directed to Winslow Health Center at (814) 332-4355.

Mailing Instructions:
Completed forms can be mailed to Winslow Health Center, 520 North Main Street, Box 26, Meadville, PA 16335,  faxed to (814) 336-3050, or emailed to whc@allegheny.edu.