Medical Referral For Homebound Instruction Due To Medical Reasons printable pdf download

Medical Referral For Homebound Instruction Due To Medical Reasons

South Bend Community School Corporation

Special Education Department

Medical Referral for Homebound Instruction Due to Medical Reasons

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

Parent/Guardian: ________________________ Phone: __________________ Work: _____________________

Address: _______________________________ City: ____________________ Zip: _______________________

School Attending: _______________________ Grade: _____ DOB: _______________ Sex: ________________

TO THE PHYSICIAN: Please answer all questions and sign where indicated.

1. Medical diagnosis of illness/injury: ______________________________________________________________

2. Explain why this medical condition prevents student from attending school: ______________________________

__________________________________________________________________________________________

3. This student will be unable to attend school for at least __________ school days. (Specify # of days)

4. This student is experiencing emotional problems and out-patient therapy services are being provided.

Yes____ No _____

Note: Before a student may receive homebound instruction, a physician must evaluate the student and state in writing

that the student has an illness or injury that requires medical treatment and extended absence from school for:

1. Absence from school for twenty (20) consecutive school days

2. An aggregate of twenty (20) school days of hospitalization

I have read and answered the above stated questions and this student meets the criteria set forth in these

guidelines to receive instruction in the home by a South Bend Community School Corporation certified

instructor.

MD Signature

MD Please print name

Address

Phone

Date

A student’s need to continue Homebound Instruction must be confirmed with a new medical referral every 90 school days, or as

deemed necessary by the Special Education Department. A parent must provide the school corporation with a written statement from

a physician with an unlimited license to practice medicine prior to the student’s return to school.

Return form to:

South Bend Community School Corporation

Special Education Department

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

Phone: 574.283.8130 Fax: 574.283.8105

7/20/10

Medical Referral For Homebound Instruction Due To Medical Reasons