Semester and Year (i.e., Fall 2019)
If you answered “yes” to any of the previous questions on this form, the following appropriate documentation must be submitted directly to the Allied Health Department Chair by the student for review and action sixty (60) days prior to anticipated enrollment in a Health Science course. Any subsequent reportable incident(s) must be immediately submitted to the Allied Health Department Chair. A copy will be retained in the Department of Allied Health records.
Reporting of subsequent arrests, convictions or impairment:
If a student is admitted to the clinical sequence of the program, any subsequent action, arrest, criminal charge or conviction or impairment shall be immediately reported to the Department of Allied Health.
Type your full name in the box to serve as your signature.
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