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

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: July 2023

Note: This form is used by the Interim Instructional Services (IIS) Office to obtain a 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.
A new completed application, with updated information from the practitioner regarding diagnosis and treatment is required for continuation of service beyond 60 calendar days.
In order for this application to be considered, ALL components of this application must be completed and submitted:
I. Parent portion including signature
II. School portion
III. Practitioner verification including specific steps the school can take to support the student returning to instruction
IV. Return to school plan: The conversation regarding the return to school plan should happen with all stakeholders prior to the submission of the application. It is preferable that the plan be submitted with the application, but it must be submitted no later than 30 days after the application submission.

The school must send the form electronically, when completed, to Delivery of IIS will be virtual. Individual exceptions will require review and approval by the Supervisor of Interim Instructional Services.  

Adobe PDF Application for Interim Instructional Services, with Qualified Physical Health Condition ONLY92 KEnglish
Adobe PDF Solicitud para Servicios Instructivos Provisionales, SÓLO con Condición Física Calificada66 KSpanish
Adobe PDF Demande de services d'enseignement provisoires, pour individus à état de santé éligible unqiuement67 KFrench
Adobe PDF Đơn cho Các Dịch Vụ Giảng Dạy Tạm Thời, CHỈ với Điều Kiện Sức Khỏe Thể Chất161 KVietnamese
Adobe PDF 臨時教學服務申請(僅限於符合條件的身體健康狀況)161 KChinese
Adobe PDF 임시 교습 서비스 지원서(승인된 신체 건강 상태인 학생용)110 KKorean
Adobe PDF በጊዜያዊነት ለሚሰጥ የትምህርት አገልግሎት ማመልከቻ፣ አ98 KAmharic
Adobe PDF Pedido de Serviços Instrucionais Provisórios, SOMENTE com Condição de Saúde Física Qualificada66 KPortuguese

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat