Common use of TO BE COMPLETED BY THE PHYSICIAN Clause in Contracts

TO BE COMPLETED BY THE PHYSICIAN. I understand that treatments may be administered in MCPS by non-health professionals. These individuals may be employees of MCPS who volunteer to administer the treatment(s), or the DHHS School Health Room Aide. These persons will be trained by the School Community Health Nurse to give the specific treatment. Student Name Diagnosis Treatment Frequency and time(s) to be provided at school If not needed on a routine basis, specify when indicated Treatment orders effective: / / To / / Possible complications and/or special considerations Equipment needed for treatment, including any special care and handling Symptoms/observations to be reported List other condition(s) and/or diagnosis(es) of student that staff need to be aware of / / Physician’s Name (Print or type) Telephone Original Signature, Physician Date

TO BE COMPLETED BY THE PHYSICIAN. I understand that treatments may be administered in MCPS by non-health professionals. These individuals may be employees of MCPS who volunteer are designated to administer the treatment(s), or the DHHS School Health Room Aide. These persons will be trained by the School Community Health Nurse to give the specific treatment. Student Name Diagnosis Treatment Frequency and time(s) to be provided at school If not needed on a routine basis, specify when indicated Treatment orders effective: / / To / / Possible complications and/or special considerations Equipment needed for treatment, including any special care and handling Symptoms/observations to be reported List other condition(s) and/or diagnosis(es) of student that staff need to be aware of / / Physician’s Name (Print or type) Telephone Original Signature, Physician Date

TO BE COMPLETED BY THE PHYSICIAN. I understand that treatments may be administered in MCPS by non-health professionals. These individuals may be employees of MCPS who volunteer are designated to administer the treatment(s), or the DHHS School Health Room AideTechnician. These persons will be trained by the School Community Health Nurse (SCHN) to give the specific treatment. Student Name Diagnosis Treatment Frequency and time(s) to be provided at school If not needed on a routine basis, specify when indicated Treatment orders effective: / / To / / Possible complications and/or special considerations Equipment needed for treatment, including any special care and handling Symptoms/observations to be reported List other condition(s) and/or diagnosis(es) of student that staff need to be aware of / / Physician’s Name (Print or type) Telephone Original Signature, Physician Date