West Haven Public Schools
West Haven Public Schools
REQUEST FOR MEDICAL/PSYCHOLOGICAL HOMEBOUND INSTRUCTION **
For Parent/Guardian To Complete (print):
Student: _______________________________ ________ ___________ _____ ________________________
Last name first name MI date of birth school grade teacher(k-5)/guidance counselor (6-12)*
Address ___________________________________ ___________ __________________________________
Street home phone student’s email (for homework-optional)
Mother ___________________________ __________ ____________ ____________ __________________
Name home phone cell phone work phone email (optional)
Father ___________________________ __________ ____________ ____________ __________________
Name home phone cell phone work phone email (optional)
Other ___________________________ __________ ____________ ____________ __________________
Name home phone cell phone work phone email (optional)
Illness or Injury affecting student’s ability to attend regular classes __________________ Date of onset ________
Attending Provider(s): ____________________________________ ____________________ _______________
Pediatrician phone fax
_____________________________________________ _________________________ ___________________
other (physical or mental health) phone fax
_____________________________________________ _________________________ ___________________
other (physical or mental health) phone fax
I hereby ____ do ____ do not authorize the health care provider(s) above to exchange information about my child’s health with the West Haven Public School Health Services and Education Departments for the purpose of assessing the need for homebound instruction. This authorization is valid beginning today and will expire one year from today. I understand that I may revoke this authorization at any time by submitting written notice of the withdrawal of my consent. I recognize that health records, once received by the school district, will become education records protected by the Family Educational Rights and Privacy Act (FERPA) rather than the HIPAA Privacy Rule.
______________________________________ _________________________________________________ _______________________
Printed Name of Parent or Guardian Signature Date
For Physician To Read and complete: State Department of Education Regulations 10-76 d-15 require the child’s treating physician shall provide a statement in writing directly to the board of education on a form provided by such board, stating: (A) the child’s treating physician has consulted with school health supervisory personnel and has determined that attendance at school with reasonable accommodations is not feasible, (B) the child is unable to attend school due to a verified medical reason. (C) the child’s diagnosis with supporting documentation, (D) the child will be absent from school for at least ten consecutive school days or the child’s condition is such that the child may be required to be absent from school for short, repeated periods of time during the school year and, (E) the expected date the child will be able to return to school.
And Complete:
Diagnosis/Reason for Homebound Instruction: ______________
Recommendations in consultation with school health personnel:
Initial: ________ ________ _______________________________ ________________________ _________
Start Date End Date Physician’s Name (print) Physician’s Signature Date
Comments:
FOR SCHOOL PERSONNEL ONLY:
Reviewed by: ____________________________________ Principal ________________________________________ ___________
Signature Signature & title date
4 week
Update:________ ________ ___________________________________ ___________________ ________
Start Date End Date Case Manager (print) Case Manager - Signature Date
*(with exclusion of expulsion) #62A Rev. 9/2013
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