INTERNATIONAL STUDENT SERVICES
DELAWARE STATE UNIVERSITY
1200 North Dupont Highway, Dover, DE 19901
Phone: 302-857-6474/Fax: 302-857-6567
Study/Travel Abroad Health/Immunization Information Form
Please complete the below questions, do not leave any questions blank!
Once you decide to travel beyond the US borders, it's wise to make an appointment with a travel health expert to discuss your general health and immunization needs. In an effort to keep our DSU and local community healthy we are requiring you to complete this form; help us to help you keep our community disease free!
Student Name:______D #______Email
U.S. Address:______
Apt# City State Zip Code
Dormitory Room No. Bldg No:
Address while abroad:______
City Country Zip Code
U.S. Telephone No.(s):______Foreign Telephone No.(s) (if applicable):______
Classification: Freshman Sophomore Junior Senior Grad PhD International
What country(ies) will you visit?
(Please use the back of this sheet if you need more additional space)
1. I will depart the USA on____/_____/____ and return to the USA on ____/_____/____
2. My passport expires on _____/_____/______
3. Are you traveling with a DSU Sponsored Program? Yes No
If yes, list the name(s) of the faculty/staff member(s)
Which college/office is he/she under?
If no, name of your Program Provider
4. Did you view the http://wwwnc.cdc.gov/Travel website and receive all of the recommend immunizations? Yes No.
If no, why not
Student signature: ______Date:______
I affirm that the statements made on this questionnaire are true and correct to the best of my knowledge. I understand that even if I did/did not receive the recommended immunizations; I will not hold Delaware State University responsible for any sickness/illness/disease(s) I may catch while traveling abroad. I am aware that the DSU Student Health Center may require students traveling abroad to get a PPD (or other immunizations) upon his/her return to Delaware State University’s campus.
Please complete and submit this form to the OIA at least two weeks prior to your anticipated travel date.
Copies: Student File/Student Health Center