K-12 Support Request

Public Health K-12 School Support Request
For Provisional Staff - 2022-2023 School Year

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 school site (no district wide requests).

We will work with you to define a scope of work for Provisional Staff that both meets the parameters of the Health Inequity Grant and your needs for support.

School Information

School Type

School District

School Name

Street Address

City

State

Zip Code

School Main Phone Number

Bilingual Preferred

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

Provisional Staff Work Schedule

Most Provisional Staff begin their workday when the school office opens.
Provisional Staff will be released from their schools at noon on Wednesdays for Professional Development.

Please Select
  M, T, TH, F: 7:00 AM - 3:00 PM (WED 7:00 AM - 12:00 PM)
  M, T, TH, F: 7:30 AM - 3:30 PM (WED 7:30 AM - 12:00 PM)
  M, T, TH, F: 8:00 AM - 4:00 PM (WED 8:00 AM - 12:00 PM)
  M, T, TH, F: 8:30 AM - 4:30 PM (WED 8:30 AM - 12:00 PM)

Please select a schedule for provisional staff.

Additional Information

Other Notes or Comments

You will be contacted by a member of the School Support Unit within one week of your request. If you don't hear from us, please call us directly at: 602.372.7999.

Schools are prioritized for staffing by their "Risk Score." The Risk Score is determined by the schools Title One Status, their proportion of minority enrollment, the staff:student ratio, and their current outbreak status. The Risk Score also takes into consideration the prevalence of COVID-19 vaccination and the percent positivity in the surrounding community.

Public Health K-12 School Support RequestFor Provisional Staff - 2022-2023 School Year

School Information

Primary Contacts for Staffing Requests

Provisional Staff Work Schedule

Additional Information

Public Health K-12 School Support Request
For Provisional Staff - 2022-2023 School Year