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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 13:42, October 7, 2019
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<td width="60%"><big>''' | <td width="60%"><big>'''Request for Waiver of Faculty Immunizations or CPR Requirements'''</big></td> | ||
<td width="40%"><big>Subsection: '''Appendix | <td valign="top" width="40%"><big>Subsection: '''Appendix M'''</big></td> | ||
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<td width="60%">Section | <td width="60%">Section - Appendices</td> | ||
<td width="40%">Originating Date: | <td width="40%">Originating Date: October 2003</td> | ||
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<td width="60%">Responsible Reviewing Agency:<br /><div style="margin-left:3em; line-height:1.2;"> | <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> | ||
</div></td> | <td valign="top" width="40%"> | ||
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<table width="100%" cellpadding="0" cellspacing="0"> | <table width="100%" cellpadding="0" cellspacing="0"> | ||
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<td>Revised: | <td>Revised: [[CON Request for Waiver of Faculty Immunizations or CPR Requirements version February 2008|February 2008]]<br />Reviewed: [[CON Request for Waiver of Faculty Immunications or CPR Requirements version May 2016|May 2016]]<br />Revised: March 2018</td> | ||
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<td valign="top">< | <td colspan="2" valign="top">Related documents:<br /><div style="margin-left:3em; line-height:1.2;">4.2.12</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 (please list):</p> | ||
<p style="margin-bottom:150px;">for the following reason(s) (ex. allergy):</p> | |||
<table style="max-width:70em !important;" width="100%" cellspacing="0" cellpadding="0" border="0"> | |||
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<td>_______________________________________________</td> | |||
<td width="75px"> </td> | |||
<td>_______________________________</td> | |||
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<td>Faculty Signature</td> | |||
<td width="75px"> </td> | |||
<td>Date</td> | |||
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<tr><td colspan="3"> </td></tr> | |||
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<td>_______________________________________________</td> | |||
<td width="75px"> </td> | |||
<td>_______________________________</td> | |||
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<td>Department Chair/Division Assistant Dean Signature</td> | |||
<td width="75px"> </td> | |||
<td>Date</td> | |||
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--> | |||
<tr><td colspan="3">Submit completed/signed form to conrecords@unmc.edu</td></tr> | |||
<tr><td colspan="3"> </td></tr> | |||
<tr><td colspan="3">Note: For recurring requirements, form should be submitted each time requirements comes due.</td></tr> | |||
<tr><td colspan="3"> </td></tr> | |||
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