Fillable COUNTY OF LOS ANGELES SCHOOL WAIVER APPLICATION FOR (County of Los Angeles / Internal Services Department)

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COUNTY OF LOS ANGELES SCHOOL WAIVER APPLICATION FOR (County of Los Angeles / Internal Services Department)

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BROWSE COUNTY OF LOS ANGELES / INTERNAL SERVICES DEPARTMENT (CA) FORMS

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Rev.10.26.2020
Full Name of School Requesting Waiver:
School Type: Date of Application:
School District Superintendent or School Head Administrator Name:
Phone: ___________________________ Email: ______________________________________
Address: ______________________________ City: ___________________ Zip: _________
School District Where Your School is Located:
Estimated total number of students that will return for in classroom instruction per grade (if
none, enter 0):
TK: _____
K: _____
1: _____
2: _____
Estimated total number of administrators, teachers, and other employees that will be
returning to
support in classroom instruction for grades TK - 2: ____________
Total number of administrators, teachers, and other staff employed by the school:
____________
Anticipated total number of cohorts returning: _________________
Anticipated mode of attendance for In-classroom instruction:
Percent of student body who qualify for Free Or Reduced-Priced Meals: _________________
URL where re-opening protocols are posted: ________________________________________
COUNTY OF LOS ANGELES SCHOOL WAIVER APPLICATION
FOR GRADES TK – 2 IN-PERSON EDUCATION
COVER SHEET
Select
10/26/20
Select
Select
Rev.10.26.2020
Supporting materials to include with this cover sheet:
☐ Letter from district superintendent or head administrator for private/charter school requesting
this waiver.
☐ Letters of support from the following groups OR in lieu of letters of support, a written attestation
signed by the superintendent/head administrator describing the consultation process with each
of the following groups, including the dates of consultation and the names of all organizations
consulted with:
☐ All labor unions representing employees at the school reopening for classroom
instruction. If school staff are not represented by a union, then the applicant must
describe the process by which it consulted with school staff.
☐ Parent organization(s) at the school reopening for classroom instruction. If there is no
representative parent organization at the school, then the applicant must describe the
process by which it consulted with parents of students at the school.
☐ Community organization(s) that provide services for students and their families who
attend the school reopening for classroom instruction.
☐ A completed Los Angeles County Department of Public Health K-12 School re-opening protocol
checklist.
By checking these boxes, I attest:
☐ Our district/school has obtained sufficient and appropriate personal protective equipment
(PPE), as defined by the reopening protocols and California Department of Public health
guidance, for all teachers and staff who will be involved in in-person instruction.
☐ A plan or protocol has been developed for incorporating surveillance testing into regular school
operations of all school personnel which describes the strategy for ensuring access to periodic
testing for all school personnel to be implemented when instructed by the Department of Public
Health based on local disease trends and/or after resolution of an outbreak at the school.
☐ I am aware that this form and all supporting documents will be posted publicly on the Los
Angeles County Department of Public Health website.
EMAIL THIS COMPLETED COVER SHEET AND ALL SUPPORTING MATERIALS TO
SchoolwaiversC19@ph.lacounty.gov.
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COUNTY OF LOS ANGELES SCHOOL WAIVER APPLICATION FOR (County of Los Angeles Internal Services Department)

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Completed 15 February 2021

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