Section 641.178.2. Sample petition for waiver.

A petition for waiver filed in accordance with 641—178.1(17A,135) must meet the requirements specified therein and must substantially conform to the following form:

BEFORE THE DEPARTMENT OF PUBLIC HEALTH
Petition by (name of petitioner) for the waiver/variance of (insert rule citation) relating to (insert the subject matter).	}	PETITION FOR WAIVER/VARIANCE

        1.            Provide petitioner’s (person asking for a waiver or variance) name, address, and telephone number. Also include the name, address, and telephone number of the petitioner’s legal representative, if applicable, and a statement indicating the person to whom communications concerning the petition should be directed.

        2.            Describe and cite the specific rule from which a waiver is requested.

        3.            Describe the specific waiver requested, including the precise scope and time period for which the waiver will extend.

        4.            Explain the relevant facts and reasons that the petitioner believes justify a waiver. Include in your answer all of the following:

        a.           Why applying the rule would result in undue hardship to the petitioner;

        b.           Why waiving the rule would not prejudice the substantial legal rights of any person;

        c.           Whether the provisions of the rule subject to the waiver are specifically mandated by statute or another provision of law; and

        d.           How substantially equal protection of public health, safety, and welfare will be afforded by a means other than that prescribed in the particular rule for which the waiver is requested.

5. Provide a history of any prior contacts between the department and petitioner relating to the regulated activity, license, registration, certification or permit that would be affected by the waiver. Include a description of each affected license, registration, certification, or permit held by the petitioner, any formal charges filed, any notices of violation, any contested case hearings held, or any investigations related to the regulated activity, license, registration, certification, or permit.

        6.            Provide information known to the petitioner regarding the department’s action in similar circumstances.

        7.            Provide the name, address, and telephone number of any public agency or political subdivision that also regulates the activity in question or that might be affected by the granting of the petition.

        8.            Provide the name, address, and telephone number of any person or entity that would be adversely affected by the granting of the waiver.

        9.            Provide the name, address, and telephone number of any person with knowledge of the relevant facts relating to the proposed waiver.

        10.           Provide signed releases of information authorizing persons with knowledge regarding the request to furnish the department with information relevant to the waiver.

I hereby attest to the accuracy and truthfulness of the above information.

Petitioner’s signature		Date