Certificate Of Incapacity - Indiana Department Of Education
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1Indiana Department of Education
Center for School Improvement and Performance
Office of Student Services
State Attendance Officer
Room 229, State House
Indianapolis, IN 46204-2798
Certificate of Incapacity
(Note: I.C. 20-8.1-3-20 requires this form to be signed by a licensed physician)
Student’s Name________________________________________________________________
Grade.
Date of Birth ___________________ Social Security Number ______________________
School ____________________Principal:_____________________ Telephone Number: _(____)______________
PART 1
(To Be Completed By the Physician)
Diagnosis of the Condition:
Duration
of
the Condition (Check One): _____ permanent
______ temporary
Anticipated Date the Student May Return to School: ______________, 20___
__
Date Student Should Return for Re-examination: ______________, 20_
PART 2
(To Be Completed by the Physician):
Based on your diagnosis and professional judgment, the school should anticipate the student's school attendance to be
(check one):
Regular Daily Attendance
Irregular Daily Attendance (please explain)
Seasonal (please explain)
If an individualized program is warranted due to anticipated irregular school attendance or restriction of physical
activities, the school may submit a written individualized program for the physician's app roval and signature.
Physician's Signature
Return form to:
Physician 's Printed Name
Physician's Address
Telephone Number
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