Medical Referral For Students With Visual Impairments printable pdf download

Medical Referral For Students With Visual Impairments

South Bend Community School Corporation

Special Education Services

215 S. St. Joseph St, South Bend, IN 46601

Ph: 574.283.8130 Fax: 574.283.810

Medical Referral for Students with Visual Impairments

Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________

School/Preschool: _______________________ DOB: ____________________ Date: _____________________

To the Physician:

The South Bend Community School Corporation provides special education and related services to students who

qualify for special education under federal and state law.

A medical referral has been initialted for the above-named student. Establishment of elitigibility for services under

one of these disabilities is made by the case conference committee. The services which are needed are identified

in an Individual Educational Plan (IEP).

We are required to have the written diagnostic statement on file. Please complete the information as indicated and

return the form to the address above. If you have any questions, please contact the Special Education Department

at 574.283.8130.

It is very important to complete the information below to assist in the educational planning for the above-named

student.

Medical Diagnosis: ____________________________________________________________________________

Comments/Concerns: __________________________________________________________________________

___________________________________________________________________________________________

Educational Implications: _______________________________________________________________________

___________________________________________________________________________________________

Physician Name: _____________________________________________________________________________

(Please Print)

(Signature)

Physician’s Address:

________________________________________________________________________

Phone: ________________________________________

Date: ___________________________________

8/6/10

Medical Referral For Students With Visual Impairments