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Application for Interim Instructional Services

About this Form

Form number: 311-15

Audience:  MCPS Staff, Parents/Guardians

Last revised: October 2016

Related Forms

Form 311-15B - Application for Interim Instructional Services,with Qualified Physical Health Condition ONLY

Form 311-15C - Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY

MCPS Form 311-15, Application for Interim Instructional Services, has been replaced by MCPS Forms 311-15B and 311-15C, as of October 2016.  See links below to the new application forms: 

MCPS 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 physician’s recommendation and parent’s permission to initiate instruction for students with a medical 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.

MCPS Form 311-15C, Application for Interim Instructional Services, with Qualified Mental Health Condition ONLY

Note: This form is used by the Interim Instructional Services (IIS) Office to obtain psychiatrist’s/psychologist’s recommendation and parent’s 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.

Adobe PDF Application for Interim Instructional Services *65 KEnglish

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* This form is not a fill-in form.

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