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Get Interim Health Clearance Form - New York University

NCE To be completed by student/faculty: Name (Print): Date of Birth: (first, mi., last) NYU N Number: Phone #: (mm/dd/yyyy) Email: NXXXXXXXX I understand that the agency to which I am assigned may require more health data than listed below. I hereby authorize New York University to release my health clearance information on this form and all associated documents, including laboratory reports and immunization waivers, to any heal.

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