University of New Haven
Student Flu Notification Form


First Name*:  
Middle Initial:
Last Name*:  
StudentID*:    
Cell Phone*:    
Email Address*:    
Undergraduate/Graduate:
If athlete, please select sport(s):    
Resident/Commuter*:
ALLERGIC to any Medication or Food:

* Should you have any questions concerning answering these questions or other concerns please contact Health Services at 203 932-7079 and ask to speak with a nurse.

  Symptoms*:


Other Symptoms:
Did you get a flu vaccine this year?:
To verify human entry, please enter the text you see in this image: