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

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        <td align="center" colspan="2"><big>'''UNIVERSITY OF NEBRASKA MEDICAL CENTER<br />COLLEGE OF NURSING'''</big></td>
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        <td width="60%"><big>'''Request for Waiver of Faculty Immunizations or CPR Requirements'''</big>(Subsection 4.2.12 in Resource Manual)</td>
        <td valign="top" width="40%"><big>Subsection: '''Appendix M'''</big></td>
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        <td width="60%">Section - Appendices</td>
        <td width="40%">Originating Date: October 2003</td>
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        <td valign="top" width="60%">Responsible Reviewing Agency:<br /><div style="margin-left:3em; line-height:1.2;">Executive Council<br />Faculty Coordinating Council</div></td>
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                	<td>Revised: [[CON Request for Waiver of Faculty Immunizations or CPR Requirements version February 2008|February 2008]]<br />Reviewed: May 2016</td>
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    	<td colspan="2" valign="top">Related documents:<br /><div style="margin-left:3em; line-height:1.2;">&nbsp;</div></td>
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<p style="margin-bottom:150px; max-width:70em !important;">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>
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    <td>_______________________________________________</td>
    <td width="75px">&nbsp;</td>
    <td>_______________________________</td>
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    <td>Faculty Signature</td>
    <td width="75px">&nbsp;</td>
    <td>Date</td>
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<tr><td colspan="3">&nbsp;</td></tr>
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    <td>_______________________________________________</td>
    <td width="75px">&nbsp;</td>
    <td>_______________________________</td>
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    <td>Department Chair/Division Assistant Dean Signature</td>
    <td width="75px">&nbsp;</td>
    <td>Date</td>
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<tr><td colspan="3">&nbsp;</td></tr>
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