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Application for Interim Instructional Services,with Qualified Physical Health Condition ONLY

About this Form

Form number: 311-15B

Audience:  Parents/Guardians, School Staff

Last revised: August 2019

Related Forms

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 physician or certified nurse practitioner recommendation and parent/guardian permission to initiate instruction for students with a physical health condition. Return completed application to student’s school counselor or principal/designee. For more information, see MCPS Regulation IOE-RB, Interim Instructional Services

PARENT/GUARDIAN: PLEASE HAVE STUDENT’S LICENSED PHYSICIAN OR CERTIFIED NURSE PRACTITIONER COMPLETE PAGE 2 OF THIS FORM AND THEN SUBMIT THE ENTIRE APPLICATION TO THE SCHOOL.

A new completed application is required for continuation of service beyond 60 calendar days.

 

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