K-12 Support Request

Public Health K-12 School Support Request

Please complete all sections in direct consultation with your site health office personnel. We are only able to process individual school requests, so please complete a separate form for each site (no districtwide requests).

One Provisional Staff member per school will be assigned as soon as possible and will work until the end of the school year.

* I understand that Provisional Staff must work a minimum of 30 hours per week, with a full time (40 hour) work week preferred.

You must check the box above to submit this form.

Need short term (i.e. :hearing/vision screening) or part time assistance? We want to help! Don't complete this form - instead, contact Scott Olson at scott.olson@maricopa.gov at the MRC for assistance.

School Information

School Type

School District

School Name

Street Address

City

State

Zip Code

School Main Phone Number

Location, Access/Entry and Parking Instructions (please be specific)

Primary Contacts for Staffing Requests

To process your request, we need the following Health Office, School and District Point of Contact (POC) information.

Please NOTE: A copy of this information will be emailed to the addresses provided.

Health Office POC

First Name

Last Name

Title

Phone Number

Email Address

If you have more than one Health Office POC, please enter their name and contact information below

School Site POC

First Name

Last Name

Title

Phone Number

Email Address

If you have more than one School Site POC, please enter their name and contact information below

District Admin POC

First Name

Last Name

Title

Phone Number

Email Address

If you have more than one District Admin POC, please enter their name and contact information below

Health Office Sub POC

Provisional Staff must work under direct supervision of the nurse/health office staff. "Line of sight" supervision is required for any Provisional Staff interaction with a student.

Provisional Staff are not permitted to manage the health office on their own when the nurse/health office staff are absent. If your nurse/health office staff is not in attendance, who will directly supervise our Provisional Staff?

First Name

Last Name

Title

Phone Number

Email Address

Scheduling Information

Provisional Staff Weekly Schedule:*

Our provisional staff must work a minimum of 30 hours per week, with a full time (40 hour) work week preferred. With these parameters, please complete your preferred schedule:

Days of the Week Support is Needed

Monday Tuesday Wednesday Thursday Friday

Shift Start Time

Shift End Time

If your schedule will not be the same M-F, please explain here:

* This schedule contains a minimum of 30 hours per week and has been approved and agreed upon by the school health office, the school administration, and the district administration.

You must check the box above to submit this form.

Additional Information

We will work with you to define a scope of work for your Provisional Staff that meets your needs for support.

Bilingual Preferred

Other Notes or Comments

You will be contacted by a School Coordinator within one week of your request.

Provisional Staff assignment order is determined by each school’s "Risk Score" which includes Title One status, minority enrollment, staff: student ratio, as well as current vaccination, outbreak and % positivity status