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


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
School Site POC
District Admin POC
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?

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

               
 * 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.
 

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