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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: July 2018

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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’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.

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