CON Request for Waiver of Faculty Immunizations or CPR Requirements: Difference between revisions
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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;" width="100%" cellspacing="0" cellpadding="0" border=" | <table style="max-width:70em !important;" width="100%" cellspacing="0" cellpadding="0" border="0"> | ||
<tr> | <tr> | ||
<td> | <td>_______________________________________________</td> | ||
<td width="75px"> </td> | <td width="75px"> </td> | ||
<td>_______________________________</td> | <td>_______________________________</td> | ||
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<tr><td colspan="3"> </td></tr> | <tr><td colspan="3"> </td></tr> | ||
<tr> | <tr> | ||
<td> | <td>_______________________________________________</td> | ||
<td width="75px"> </td> | <td width="75px"> </td> | ||
<td>_______________________________</td> | <td>_______________________________</td> |
Revision as of 09:46, October 3, 2013
Home | Appendices |
UNIVERSITY OF NEBRASKA MEDICAL CENTER COLLEGE OF NURSING |
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Request for Waiver of Faculty Immunizations or CPR Requirements(Subsection 4.2.12 in Resource Manual) | Subsection: Appendix M | |
Section - Information | Originating Date: October, 2003 | |
Responsible Reviewing Agency: Executive Council Faculty Coordinating Council |
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J:/RESOURCE MANUAL/Table of Contents College of Nursing Resource Manual |
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 |