Follow these instructions when applying for a temporary waiver. 

• A specific correction date must be provided. The date must be between 91 and 365 days from the date of the MOH survey exit date found in the MOH Statement of Deficiencies cover letter.
• This 2786R form must be used for all temporary waiver requests.
• Fill in the facility name, 24_ _ _ _ ID # and city on the top of this form.
• A separate form is required for each individual temporary waiver request.
• List the k-tag number and the deficiency in the column to the left on this form.
• Follow the sample format. All parts must be complete. Waiver requests can be multiple pages.

Most important: 

• List all of the additional safeguards that will be put in place to assure resident Vs staff/visitor 
  safety during the term of this temporary waiver.
• Fire safety provisions already required by the code are not considered as "additional safeguards". 
  Questions on "required" vs "additional" can be answered by your State Fire Safety Inspector.

Example: Annual service contracts for safety systems are not additional safeguards. They are 
required.

The instructions below are for long-term care facilities only:

• This 2786R form must be used for all waiver requests.
• Fill in the complete facility name and city at the top of form.
• A separate waiver form needs to be completed for each K-tag waiver being requested.
• List the K-tag number and deficiency in the column on the left side of the form.
• Follow the format on the K521 sample. Both parts A. & B. must be completed
• Use those statements shown on the sample that apply to your facility.
• Additional justification statements may be, should be, listed.
• Waivers can be multiple pages.

Remember, you are trying to justify why you should not be required to comply with the exact prescriptive requirements of the fire safety code.