Transcription of MIAMI-DADE COUNTY PUBLIC SCHOOLS PHYSICIAN´S STATEMENT ...
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
