SECTION IV. AUTHORIZATION FOR RELEASE OF IMMUNIZATION AND SCREENING INFORMATION
Student Written Permission
I, ________________________________________, authorize the National Louis University Physician Assistant Program and/or authorized University personnel to release the limited immunization and/or health-screening compliance information identified below to the authorized recipient identified in this section.
NLU Student ID Number: ___________________________________
Information Authorized for Release
☐ Immunization Compliance Verification ☐ Tuberculosis Screening Compliance Verification
☐ Health Screening Compliance Verification ☐ Clinical-Site-Specific Compliance Verification ☐ Other: _________________________________________________
Authorized Recipient
Clinical Affiliate/Organization:
Authorized Contact/Department:
Purpose of Release
☐ Verification of eligibility for clinical placement
☐ Verification of clinical-site health and safety requirements
☐ Other: _________________________________________________
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