Faculty of Science

AMBULATORY BLOOD PRESSURE MONITORING IN THE TRU SLEEP CLINIC:
SHOULD HIGH BLOOD PRESSURE AND SLEEP APNEA BE TESTED FOR AND
TREATED SIMULTANEOUSLY?
2014 | KAYLA ANN HOLTSLAG

B.Sc. Honours thesis

AMBULATORY BLOOD PRESSURE MONITORING IN THE TRU SLEEP CLINIC:
SHOULD HIGH BLOOD PRESSURE AND SLEEP APNEA BE TESTED FOR AND
TREATED SIMULTANEOUSLY?
by

KAYLA ANN HOLTSLAG
A THESIS SUBMITTED IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
BACHELOR OF SCIENCE (HONS.)
in the
DEPARTMENT OF BIOLOGICAL SCIENCES
(Cellular, Molecular, and Microbial Biology)

We accept this thesis as conforming to the required standards:
_________________________________________
Nancy Flood (Ph.D.), Thesis Supervisor, Dept. Biological Sciences
_________________________________________
Les Matthews, Co-supervisor, Dept. Respiratory Therapy
__________________________________________
Jonathan Van Hamme (Ph.D.), Dept. Biological Sciences
Dated this 22nd day of April, 2014, in Kamloops, British Columbia, Canada

i

ABSTRACT
Extensive research has demonstrated a strong correlation between obstructive sleep
apnea (OSA) and high blood pressure (hypertension). Furthermore, studies have shown
that treating OSA can lead to an improvement in blood pressure levels. Despite this
knowledge, many sleep clinics still do not test their patients for hypertension and have
yet to develop comprehensive treatment plans that aim to target both OSA and
hypertension. The TRU Sleep Clinic currently sees patients referred by local physicians
for overnight ambulatory blood pressure (ABP) monitoring; upon their first visit, the
patients are questioned regarding their sleep habits and complete questionnaires
designed to reveal the level of risk for OSA. Despite this effort, patients are not
returning to the clinic for further screening and treatment for OSA. The purpose of this
study was to identify ABP patients whose files had been archived, but who should have
been tested for OSA, invite those patients back to the clinic for further testing, and
determine how to ensure that people do return to the clinic in the future if they are
identified as at risk for OSA. To do so, I reviewed 182 archived ABP patient files to
identify those patients who demonstrated a risk of OSA during the initial screening
process. Then, I contacted those patients and invited them back to the clinic for
overnight pulse-oximetry, partly to determine how willing patients were to return to
the clinic for OSA testing. I designed a script for contacting patients that emphasized
the connection between hypertension and OSA and the possible benefits of treating
ii

OSA for their overall health. Finally, I developed an improved ABP patient archive
form in order to ensure that when a patient demonstrates a risk of OSA, their file would
not be prematurely archived. Based on their Epworth Sleepiness Scale and STOP-BANG
questionnaire scores, and their self-reported sleep issues, 48 of the 182 patients should
have been invited back to the clinic for overnight pulse-oximetry to test for OSA. Of
those, 20 were contacted successfully and 10 agreed to return to the clinic for pulse-ox.
The conclusions from this study were that more than a quarter of the patients who
initially visited the clinic for overnight ABP monitoring should have returned for pulse
oximetry, a substantial proportion of patients were willing to return to the clinic for
further testing, and that a new “Request to Archive ABP Patient File” form was
necessary in the clinic to ensure that ABP patients demonstrating a risk for OSA were
being identified and not archived.

Thesis Supervisor: Senior Lecturer Dr. Nancy Flood

iii

ACKNOWLEDGEMENTS
I would like to thank my supervisors, Dr. Nancy Flood and Les Matthews for their
support throughout the project. Also, thanks to CUEF-UREAP for providing funding
and the TRU Sleep Clinic for allowing my research to take place in their facilities.

iv

TABLE OF CONTENTS

SECTION TITLE

PAGE

Title Page

i

Abstract

ii

Acknowledgments

iii

Table of Contents

iv

1. Introduction

1

2. Materials and Methods

6

3. Results and Discussion

8

4. Conclusion

11

5. References

12

6. Appendices

14

v

INTRODUCTION
Obstructive sleep apnea (OSA) is a common health concern that often goes
undiagnosed; in 2010, it was reported that approximately 3% of Canadians over 18 and
5% of Canadians over 45 have been diagnosed with OSA, and 26% of Canadian adults
were at risk for OSA based on specific risk factors (Public Health Agency of Canada
2009). For example, there is an increased risk in certain populations, including males
and post-menopausal women, overweight/obese people, the elderly, certain ethnic
minorities, and those who have a history of OSA in their family (Academy of Sleep
Medicine, 2008). Increased risk is most commonly associated with enlarged
oropharyngeal structures, structures which comprise the middle portion of the throat
between the soft palate and epiglottis. Genetic factors and obesity are both known to
contribute to enlargement of these structures, factors which explain why the
aforementioned populations have higher representation (Schellenberg et al., 2000).
Many studies have attempted to find a direct causal link between OSA and various
comorbidities due to the high prevalence of conditions such as high blood pressure
(hypertension) in patients who also have OSA. The proportion of patients with both
OSA and hypertension can be high (Cohen and Townsend, 2013; Friedman and Logan,
2009; Kapur and Weaver, 2012; Marin et al., 2012). For example, one study found that
the prevalence of OSA in adults with drug-resistant hypertension was 83% (Logan et al.,
2001). OSA was diagnosed in these cases when patients had an apnea-hypopnea index
1

(AHI) of greater than 10. The AHI is a metric for scoring OSA severity based on the
number of absent or decreased respirations per hour; an AHI of 5-15 is classified as mild
OSA, an AHI of 15-30 is moderate, and an AHI of >30 is severe (Public Health Agency
of Canada, 2009).
There are many confounding variables that can contribute to both OSA and
hypertension (or other comorbidities), making causal relationships difficult to confirm.
Studies have shown that treatment for OSA using continuous positive airway pressure
(CPAP) can lead to lower blood pressure in hypertensive patients (Haentjens et al.,
2007). CPAP is the typical treatment for OSA that consists of a mask worn over the nose
and a machine that produces a continuous flow of air through the nasal passage,
keeping the airway open (Canadian Lung Association, 2012) (Figure 1). The fact that
CPAP therapy has the potential to lower blood pressure suggests that OSA may in fact
be causing, or at least contributing to, hypertension in some cases. Due to the strong
correlation between OSA and hypertension, and the fact that there is evidence of OSA
contributing to hypertension, the Thompson Rivers University (TRU) Sleep Clinic has
made efforts to screen all of those patients who are referred to the clinic for overnight
ambulatory blood pressure (ABP) monitoring for OSA as well.

2

Figure 1. CPAP therapy involves a machine that pumps air continuously though a hose
connected to a mask that is worn over the nose (Harvard Health Publications, 2013).

Ambulatory blood pressure (ABP) monitoring is a method of measuring a patient’s
blood pressure (BP) at set intervals overnight, as opposed to a one time measurement
done in a physician’s office. Several physicians in Kamloops refer patients that display
hypertension during the office-based test to the TRU Sleep Clinic for overnight
monitoring. This allows the physician to view a patient’s BP overnight when a person
with normal BP would usually experience a “dip” or temporary decrease in BP. A
person with hypertension however, is often a “non-dipper”, therefore does not have the
normal overnight drop in BP (Verdecchia, 1991). Non-dipping hypertension has also
been directly connected to OSA and so the clinic could use this information as an
indicator of possible OSA (Stergiou et al., 2013). ABP monitoring also tends to alleviate

3

false measurements as a result of “white coat hypertension”, the case where a patient
has higher than usual BP readings in the doctor’s office (Anwar and White, 2001, Manci
et al., 2011). ABP monitoring has been shown to be far more accurate for diagnosis
compared to home or office-based blood pressure measurements (Hodgkinson et al.,
2011).
At TRU, each patient who visits the clinic for ABP monitoring is asked to complete two
standardized OSA screening questionnaires, the Epworth Sleepiness Scale (ESS) and the
STOP-BANG questionnaire (see Appendix I & II), and is asked general questions about
their sleeping habits. The ESS questionnaire was developed in 1991 by Dr. Murray
Johns in order to measure daytime sleepiness, which is one of the clearest symptoms of
OSA (Johns, 1991). The STOP-BANG questionnaire, or loud Snoring, Tiredness,
Observed apnea, high blood Pressure (STOP)-Body-mass index, Age, Neck
circumference, and Gender (BANG) questionnaire, is used to determine the likelihood
of OSA based on other symptoms and risk factors of OSA including loud snoring,
tiredness, high body-mass index etc. (Chung et al., 2013). By employing these methods,
clinic personnel hope to get those patients who show a risk of OSA to return to the
clinic after their ABP monitoring is complete to receive formal screening and possibly
treatment for OSA.
However, as my review of the archived ABP patient file revealed, there has been a lack
of follow-through at the TRU Sleep Clinic with ABP patients who also showed signs of
4

OSA. Many of the ABP patients had ESS and STOP-BANG scores that would indicate
that they might be suffering with OSA. Many times, no mention of this was made on
the “Request to Archive Patient File” form. Sometimes, the student who conducted the
appointment did note that the patient would be a good candidate for OSA, yet still
requested to archive the file. As such, the patient would be advised to request a new
referral to the clinic for OSA and their file archived. However, a new referral is not
necessary to give a pulse oximetry test meaning that this should have been offered to
the patient immediately. Pulse oximetry measures oxygen saturation in the blood and
therefore reveals whether a patient is breathing effectively at night; this is how the TRU
Sleep Clinic screens for OSA.
The ABP patient archival process, with the requirement of a supervisor signature, was
designed to ensure that students conducting patient appointments were archiving
patient files when appropriate. This would ensure that each patient’s ABP results were
sent to the doctor, that the patient did not have outstanding equipment loans, and that
the student could make additional comments. The additional comments section was
where I often found the information that the patient showed signs of OSA. However,
despite this system, ABP patient files were still being archived prematurely, before the
patient had been offered testing and treatment for OSA. What the document lacked was
a section where the student recorded specific data regarding the patient’s risk for OSA;
this would incorrectly demonstrate to the supervisor reviewing the request form that
5

the patient had received all the care that the clinic could provide and that the file should
thus be archived. My goal was to determine how many archived ABP patients should
have returned to the clinic for proper OSA testing, how to get those patients to return to
the clinic for pulse oximetry, and how to ensure patients’ files are not prematurely
archived in the future.
MATERIALS AND METHODS
In order to determine how many ABP patient files were prematurely archived, I
reviewed all 182 archived files thoroughly over the course of a month. Each file took
approximately 30 minutes to review, depending on the patient and the content of the
file. I noted their ESS and STOP-BANG scores and their self-reported sleep issues. If
their ESS score was above 10, their STOP-BANG score was above 2, and/or they
reported loud snoring or daytime sleepiness, I included them in my contact list.
Through my file review, I learned the issues with the process of archiving currently
being used in the clinic and I developed a new “Request to Archive ABP Patient File”
form to address those issues. I collaborated with the director of the Respiratory Therapy
(RT) program at TRU and the RT students working in the clinic to determine what was
needed on the new form. I added a section to the form in which RT students who
conduct appointments must report patients’ ESS and STOP-BANG scores, whether they

6

report any of the common symptoms of OSA, and whether patients are offered
overnight pulse oximetry (See Appendix III).
Once I determined which patients were to be contacted, I developed a script for
contacting patients (approved by the TRU Human Ethics Review Board – File Number
100374; See Appendix IV) that focused on the recognized connection between
hypertension and OSA, and the possible benefits to their health if they were to be
treated for OSA. After contacting the patients and setting up appointments, I showed
each patient how to use the pulse oximetry monitor overnight and instructed them to
bring it back the following day. Pulse oximetry uses light waves to measure the relative
concentrations of hemoglobin (HB) and oxyhemoglobin (O2Hb) in the blood by
measuring the absorbance of the light waves, thus revealing the saturation of oxygen in
the blood (Sinex, 1999).
I then downloaded the data and calculated their KDI (Kamloops Desaturation Index)
score to determine their level of risk. The desaturation index (DI) is the measurement
usually used for pulse oximetry data analysis. DI calculates the number of times per
hour that the oxygen saturation in the blood dropped by 4%. KDI is a calculation
developed by the TRU sleep clinic as a more sensitive measure of whether a person is at
risk for OSA. Instead of a drop by 4%, the KDI calculates the percentage of relevant time
that the patient had a saturation value below 90% because that would indicate
substantial disturbances in the patient’s breathing. KDI = DI [1 + (% <90/10)] where DI =
7

desaturation index; % <90 (as a decimal value) = the percentage of those desaturations
that were below 90%. Any patient with a KDI value above 6 likely has at least mild OSA
and, as that value increases, so does the probability of the presence of higher severity
OSA. If the KDI value is below 6, this method is not sensitive enough to determine
whether the patient is experiencing apneas and in this case, further testing is
recommended.
RESULTS AND DISCUSSION
The review of the archived ABP patient files revealed that 26% (48/182) of the patients
showed symptoms of OSA based on the previously mentioned criteria (Figure 2A). This
is in agreement with the high correlation between hypertension and OSA that has been
demonstrated in previous research (Cohen and Townsend, 2013; Friedman and Logan,
2009; Kapur and Weaver, 2012; Logan et al., 2001; Marin et al., 2012). After learning the
number of patients in the clinic that should have been formally tested for OSA and
possibly treated, it was important to attempt to get those patients to return to the clinic
to assess their sleep issues. I was concerned that contacting patients, who had already
been diagnosed with high blood pressure to inform them that they also possibly have
OSA and that they should return to the clinic for more testing, would be unsuccessful.
The script I developed for contacting patients was designed to focus on the research
showing that hypertension and OSA are highly correlated and that treating for OSA,
when it is present, can effectively lower blood pressure.
8

Figure 2. Results of archived ABP patient file review and patient contact. 48/182 archived
patients showed symptoms of OSA and should have been offered further testing (pulse
oximetry) for OSA. 20/48 patients were successfully contacted and 10 agreed to return to the
clinic for pulse oximetry. 4/10 patients had KDI scores over 6 and were advised to ask for a
formal referral from their doctor for a CPAP trial.

Some of the patients I attempted to contact had originally come in as early as 2008, so
contacting them was particularly difficult because many had changed their contact
information, moved, or were deceased. Of the 48 patients identified, I successfully
contacted only 20, and out of these, 10 agreed to come back to the TRU Sleep Clinic for
overnight pulse oximetry to screen for OSA (Figure 2B). Of the 10 people who
underwent a pulse oximetry test, 4 had KDI values above the threshold (Figure 2C) and
9

were advised to seek a formal referral to the clinic for a CPAP trial. Confidentiality
issues prevented me from following up with these patients regarding their actions. The
other 6 patients were notified that their pulse oximetry results indicated that they
probably did not have OSA; if they were still concerned with their sleep, I advised them
to consider taking a polysomnogram at the hospital, a much more comprehensive
overnight test, to identify other sleep issues. Overall, the 50% return rate was much
higher than expected. I concluded that if patients understand the connection between
hypertension and OSA, and the potential benefits to their health from treating OSA,
they are usually willing to undergo more testing. Furthermore, if these facts were
presented to the patient early, for example during their initial patient visit after they are
referred to the clinic for ABP monitoring, and the testing was offered to them at that
time, I predict that patients would be even more receptive to the additional test.
The aspect of this project that I hope will make the largest improvement on the lack of
follow-through identified herein is the new “Request to Archive ABP Patient File” form.
The new form includes a section for students to report patients’ ESS and STOP-BANG
scores as well as any sleep issues reported during the initial patient contact
appointment. By including this information, the supervisor, who must sign the form
before the file may be archived, will be able to determine whether the patient shows
signs of OSA and, if so, if the patient was offered a pulse oximetry test. While reviewing
files, I often noticed that RT students put notes in the file that the patient would be a
10

good candidate for OSA, yet files were still archived and students recorded that they
would await a referral from the doctor. However, once a file is archived, it is not
revisited by clinic personnel so if a referral from a doctor never arrived, this patient
would not be offered testing. The new form will eliminate the possibility of ABP
patients with signs of OSA being overlooked and the files being prematurely archived.
CONCLUSION/FUTURE WORK
The literature review for this project clearly revealed that hypertension and OSA are
strongly correlated, as expected, and that hypertensive patients should always be
screened for OSA. Since recent research has shown that treating OSA with CPAP can
effectively lower blood pressure in hypertensive patients, it would appear these two
conditions should also be treated together. This project was successful in identifying a
major gap in the process of archiving files in the TRU Sleep Clinic, where ABP patients
who also qualified for OSA were not being consistently offered formal screening for
OSA. By illuminating this problem and developing the new “Request to Archive ABP
Patient File” form, there will be an opportunity for this clinic to build its own database
of patients who are being treated for both hypertension and OSA which will open up
possibilities for future studies in the clinic. By continuing to study the connection
between these two health problems, the TRU Sleep Clinic can be an example of positive
change and raise awareness about the efficacy of testing for and treating hypertension
and OSA simultaneously.
11

LITERATURE CITED:
Anwar, Y. A., and White, W. B. (2001). “Ambulatory monitoring of blood
pressure”. Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics. Humana
Press. 57-75.
Chung, F., Yang, Y., and Liao, P. (2013). Predictive Performance of the STOP-Bang Score
for Identifying Obstructive Sleep Apnea in Obese Patients. Obes. Surg. 23, 2050–2057.
Cohen, D.L., and Townsend, R.R. (2013). Obstructive Sleep Apnea and Hypertension. J.
Clin. Hypertens. 15, 703.
Friedman, O., and Logan, A.G. (2009). The Price of Obstructive Sleep Apnea–Hypopnea:
Hypertension and Other Ill Effects. Am. J. Hypertens. 22, 474–483.
Haentjens, P., Van Meerhaeghe, A., Moscariello, A., De Weerdt, S., Poppe, K., Dupont,
A., and Velkeniers, B. (2007). The impact of continuous positive airway pressure on
blood pressure in patients with obstructive sleep apnea syndrome: evidence from a
meta-analysis of placebo-controlled randomized trials. Arch. Intern. Med. 167, 757–764.
Hodgkinson, J., Mant, J., Martin, U., Guo, B., Hobbs, F.D.R., Deeks, J.J., Heneghan, C.,
Roberts, N., and McManus, R.J. (2011). Relative effectiveness of clinic and home blood
pressure monitoring compared with ambulatory blood pressure monitoring in
diagnosis of hypertension: systematic review. BMJ 342, d3621–d3621.
Johns, M.W. (1991). A New Method for Measuring Daytime Sleepiness: The Epworth
Sleepiness Scale. Sleep 14, 540–545.
Kapur, V.K., and Weaver, E.M. (2012). Filling in the Pieces of the Sleep Apnea–
Hypertension PuzzleThe Pieces of the Sleep Apnea–Hypertension Puzzle. JAMA 307,
2197–2198.
Logan, A.G., Perlikowski, S.M., Mente, A., Tisler, A., Tkacova, R., Niroumand, M.,
Leung, R.S., and Bradley, T.D. (2001). High prevalence of unrecognized sleep apnoea in
drug-resistant hypertension. J. Hypertens. 19, 2271–2277.
Mancia, G., Bombelli, M., Seravalle, G., & Grassi, G. (2011). Diagnosis and management
of patients with white-coat and masked hypertension. Nature Reviews Cardiology. 8,
686-693.

12

Marin, J.M., Agusti, A., Villar, I., Forner, M., Nieto, D., Carrizo, S.J., Barbe, F., Vicente,
E., Ying, W., Nieto, F.J., et al. (2012). Association Between Treated and Untreated
Obstructive Sleep Apnea and Risk of Hypertension. J. Am. Med. Assoc. 307, 2169–2176.
Schellenberg, J.B., Maislin, G., and Schwab, R.J. (2000). Physical findings and the risk for
obstructive sleep apnea: The importance of oropharyngeal structures. Am. J. Respir.
Crit. Care Med. 162, 740–748.
Sinex, J. E. (1999). Pulse oximetry: principles and limitations. Am. J. Emerg. Med. 17, 5966.
Stergiou, G.S., Triantafyllidou, E., Cholidou, K., Kollias, A., Destounis, A., Nasothimiou,
E.G., Markozannes, E., and Alchanatis, M. (2013). Asleep home blood pressure
monitoring in obstructive sleep apnea. Blood Press. Monit. 18, 21–26.
Unknown Author (2008). Academy of Sleep Medicine: Obstructive Sleep Apnea.
http://www.aasmnet.org/resources/factsheets/sleepapnea.pdf (accessed February 21,
2014).
Unknown Author (2012). Canadian Lung Association: C.P.A.P.
http://www.lung.ca/diseases-maladies/apnea-apnee/cpap-cpap/index_e.php (accessed
April 26, 2014).
Unknown Author (2009). Public Health Agency of Canada. What is the Impact of Sleep
on Canadians: Fast Facts from the 2009 Canadian Community Health Survey - Sleep Apnea
Rapid Response. http://www.phac-aspc.gc.ca/cd-mc/sleepapnea-apneesommeil/ff-rr2009-eng.php (accessed February 21, 2014).
Verdecchia, P., Schillaci, G., and Porcellati, C. (1991). Dippers versus non-dippers. J.
Hypertens. Supplement: official journal of the International Society of Hypertension 9,
S42-4.
Watson, S (2013). Harvard Health Publications: Weight loss, breathing devices still best for
treating obstructive sleep apnea. http://www.health.harvard.edu/blog/weight-lossbreathing-devices-still-best-for-treating-obstructive-sleep-apnea-201310026713 (accessed
April 26, 2014).

13

APPENDIX I
THOMPSON RIVERS UNIVERSITY
CENTER FOR RESPIRATORY HEALTH AND SLEEP SCIENCE
Room S301 900 McGill Rd, Kamloops, BC V2C 0C8
Phone: 250-371-5952
Fax: 250-371-5771
Email: studentsleepclinic@tru.ca

FORM #7: ESS QUESTIONNAIRE

(5 min)

PATIENT

Age

DOB (mm/dd/yy)

Male / Female

Student Name

Date

Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following situations (as opposed to
just feeling tired)? This refers to your normal/typical way of life in recent times. Even if
some of these situations have not occurred recently, imagine how they may affect you.
Circle the appropriate number for each situation;
Situation

Never

Slight
chance

Moderate
chance

High
chance

Sitting and reading

0

1

2

3

Watching TV

0

1

2

3

Sitting, inactive, in a public place (eg; theatre,
meeting)

0

1

2

3

A passenger in a car for an hour, without a break

0

1

2

3

Laying down in the afternoon

0

1

2

3

Sitting and talking to someone

0

1

2

3

Sitting quietly after lunch (without alcohol)

0

1

2

3

Driving a car, stopped for a few minutes in traffic

0

1

2

3

Total Score: _______ / 24
14

APPENDIX II

APPENDIX III
15

THOMPSON RIVERS UNIVERSITY
CENTER FOR RESPIRATORY HEALTH AND SLEEP SCIENCE
Room S301 900 McGill Rd, Kamloops, BC V2C 0C8
Phone: 250-371-5952

Fax: 250-371-5771

Email: studentsleepclinic@tru.ca

FORM #13: REQUEST TO ARCHIVE ABP PATIENT FILE

DATE:
Male / Female

PATIENT
DOB (mm/dd/yy)

Age

Phone

H

Preferred Contact #

W

C







Email
Address

City

Province

Postal Code

Referring Physician

Family Physician

Initial Contact Date:

Last Contact Date:

Results of ABP:

Normal

High Normal

 Hypertension: circle one
(mild, moderate, severe)

Check reason for request to archive patient file:


Patient does not wish to be contacted again by the clinic



Phone number is no longer in service



New phone number cannot be determined after call to family physician



Patient is complete and has not made contact / returned calls within the last year.



Patient is deceased



Patient was referred, but has not responded to initial contact in 6 months.

Date:

(Patient now requires new referral)
Check off as ascertained from patient file and documentation:

16

 Patient does NOT have TRU equipment
Date of Equipment Return: _____________________________
 Patient DOES have the following equipment;


CPAP



Humidifier



Mask



Pulse Oximeter

Sleep Information:
ESS Score:

__________

Stop-Bang Score:

__________

Was the patient encouraged to undergo overnight pulse-oximetry?

Yes No

Did the patient report:
Snoring
Bruxism
Episodes of apnea
Restless sleep
Daytime fatigue

 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No

Comments:_______________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

_____________________________________
Print Student Name

_______________________________________
Signature, SRT

_____________________________________

_______________________________________

Faculty Name

Faculty Signature



Request Accepted

Date of Archive: ___________________________

17

APPENDIX IV

18