Forms → Staff → Interim Instructional Services → Application for Interim Instructional Services,with Qualified Physical Health Condition ONLY
Form number: 311-15E
Audience: Parents/Guardians, School Staff
Last revised: August 2020
Form 311-15D - 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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