CON Request for Waiver of Faculty Immunizations or CPR Requirements: Difference between revisions

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         <td width="60%">Section - Information</td>
         <td width="60%">Section - Information</td>
         <td width="40%">Originating Date: October, 2003</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>
         <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: February, 2008</td>
                 <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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Revision as of 10:54, June 2, 2016

Home   Appendices                    


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 - Information Originating Date: October 2003
Responsible Reviewing Agency:
Executive Council
Faculty Coordinating Council
Revised: February 2008
Reviewed: May 2016


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