About this Form
Form number: 311-15C
Audience: Parents/Guardians, School Staff
Last revised: November 2016
Form 311-15B - Application for Interim Instructional Services,with Qualified Physical Health Condition ONLY
Note: This form is used by the Interim Instructional Services (IIS) Office to obtain psychiatrist’s/psychologist’s recommendation and parent/guardian permission to initiate instruction for students with a mental health condition. Return completed application to student’s school counselor or principal/designee.
A new completed application is required for continuation of service beyond 60 calendar days.
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