Forms → Staff → Interim Instructional Services → Application for Interim Instructional Services, with Qualified Physical Health Condition ONLY
Form number: 311-15B
Audience: Parents/Guardians, School Staff
Last revised: August 2021
This form is used by the Interim Instructional Services (IIS) Office to obtain a physician or certified nurse practitionerrecommendation 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 is required for continuation of service beyond 60 calendar days.
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