Homebound Instruction Medical Certification Of Need printable pdf download

HOMEBOUND INSTRUCTION

MEDICAL CERTIFICATION OF NEED

Homebound instruction shall be made available to students who are confined at home or in a health care facility for

periods that would prevent normal school attendance (8VAC20-131-180). The term “confined at home or in a health

care facility” means the student is unable to participate in the normal day-to-day activities typically expected during

school attendance; and, absences from home are infrequent, for periods of relatively short duration, or to receive health

care treatment. Students receiving homebound instruction may not work or participate in extra-curricular activities, non-

academic activities (such as field trips), or community activities unless these activities are specifically outlined in the

students medical plan of care or the Individualized Education Program (if applicable).

To be completed by the licensed physician or licensed clinical psychologist providing care to the student for the

condition for which the services are requested.*

1. Name of Student: _______________________________________________________________________________

2. Name of School: ____________________________________________________ Grade:_____________________

3. Nature and extent of illness: _______________________________________________________________________

________________________________________________________________________________________________

4. Date of examination or diagnosis of this illness: _______________________________________________________

5. Is the student confined at home or in a health care facility?  YES  NO

6. Is the illness/treatment intermittent in nature (e.g., sickle cell anemia, chemotherapy for

childhood cancer)?  YES  NO

7. Could this child attend school if accommodations are made by the school?  YES  NO

If yes, please list the accommodations required. If no, please explain ______________________________________

________________________________________________________________________________________________

8. Estimated date of return to school: _________________________________________________________________

9. Explain ongoing treatment and/or therapy being provided:_______________________________________________

________________________________________________________________________________________________

10. Frequency of treatment: _________________________________________________________________________

___________________________________________

_____________________

Signature of Licensed Physician/Clinical Psychologist

Date

______________________________________________

_________________________

Print Physician/Psychologist Name

Telephone Number

__________________________________________________________________________________

(OVER)

Office Address

City, State and Zip Code

Homebound Instruction Medical Certification Of Need