CON Request for Waiver of Faculty Immunications or CPR Requirements version May 2016

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UNIVERSITY OF NEBRASKA MEDICAL CENTER
COLLEGE OF NURSING
Request for Waiver of Faculty Immunizations or CPR Requirements(Subsection 4.2.12 in Resource Manual) Subsection: Appendix M
Section - Appendices Originating Date: October 2003
Responsible Reviewing Agency:
Executive Council
Faculty Coordinating Council
Revised: February 2008
Reviewed: May 2016
Related documents:
 


I, ________________________________________________, request a waiver of requirements for the following immunization(s) and or CPR, and include a signed statement from my primary care provider if for medical reasons:

for the following reason(s):

_______________________________________________   _______________________________
Faculty Signature   Date
 
_______________________________________________   _______________________________
Department Chair/Division Assistant Dean Signature   Date