MIAMI-DADE COUNTY PUBLIC SCHOOLS …

FM-1920 Rev. (01-20) MIAMI-DADE COUNTY PUBLIC SCHOOLSPHYSICIAN S STATEMENT(formerly entitled Report of Medical Examination)The MIAMI-DADE COUNTY PUBLIC school district seeks information from you for thepurpose of education planning. Please complete the form, sign, and return to theaddress by school :Student NameStudent ID NumberSchoolDate of BirthParent NameParent TelephoneCompleted by physician :Nature and extent of physical/health/medical conditionDate of onsetPrognosisMedication prescribed/DosageHow does this condition impact the student?Signature and Title of Examining PhysicianDate of ExaminationPhysician's Name (Print or type) physician 's Mailing Address/Telephone Number

FM-1920 Rev. (05-05) MIAMI-DADE COUNTY PUBLIC SCHOOLS PHYSICIAN´S STATEMENT (formerly entitled Report of Medical Examination) The Miami-Dade County Public School district seeks information from you for the

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Transcription of MIAMI-DADE COUNTY PUBLIC SCHOOLS …

1 FM-1920 Rev. (01-20) MIAMI-DADE COUNTY PUBLIC SCHOOLSPHYSICIAN S STATEMENT(formerly entitled Report of Medical Examination)The MIAMI-DADE COUNTY PUBLIC school district seeks information from you for thepurpose of education planning. Please complete the form, sign, and return to theaddress by school :Student NameStudent ID NumberSchoolDate of BirthParent NameParent TelephoneCompleted by physician :Nature and extent of physical/health/medical conditionDate of onsetPrognosisMedication prescribed/DosageHow does this condition impact the student?Signature and Title of Examining PhysicianDate of ExaminationPhysician's Name (Print or type) physician 's Mailing Address/Telephone Number