CON Request for Waiver of Faculty Immunizations or CPR Requirements

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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