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CON Request for Waiver of Faculty Immunizations or CPR Requirements: Difference between revisions
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CON Request for Waiver of Faculty Immunizations or CPR Requirements (view source)
Revision as of 09:44, October 3, 2013
, October 3, 2013no edit summary
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<p style="margin-bottom:150px;">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:</p> | <p style="margin-bottom:150px;">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:</p> | ||
<p style="margin-bottom:150px;">for the following reason(s):</p> | <p style="margin-bottom:150px;">for the following reason(s):</p> | ||
<table style="max-width:70em !important; | <table style="max-width:70em !important;" width="100%" cellspacing="0" cellpadding="0" border="0"> | ||
<tr> | <tr> | ||
<td>_____________________________________</td> | <td>_____________________________________</td> | ||
| Line 64: | Line 64: | ||
<tr> | <tr> | ||
<td>Faculty Signature</td> | <td>Faculty Signature</td> | ||
<td width="75px"> </td> | |||
<td>Date</td> | |||
</tr> | |||
<tr><td colspan="3"> </td></tr> | |||
<tr> | |||
<td>_____________________________________</td> | |||
<td width="75px"> </td> | |||
<td>_______________________________</td> | |||
</tr> | |||
<tr> | |||
<td>Department Chair/Division Assistant Dean Signature</td> | |||
<td width="75px"> </td> | <td width="75px"> </td> | ||
<td>Date</td> | <td>Date</td> | ||
</tr> | </tr> | ||
</table> | </table> | ||