CHILD FIND FOR MEDICAL RELATED CONDITIONS, TEMPORARY DISABILITY, AND/OR MED-1 Student: ID #: DOB: Gr.: Campus: DIRECTIONS: Nurses will complete this form as part of the District s medical child find and health screening obligations. If the disabling condition is a current medical condition or temporary condition (that will last at least six (6) months), complete the information requested on this page. Depending on the condition, upon receipt of this form either the campus RtI Case Manager or the 504 Coordinator should initiate appropriate screening and referral procedures or establish that there is no connection or need at the present time. Date: Child Find Only (form to remain in nurse records) Medical Conditions Refer to 504 (does NOT include AD/HD, CD, OCD, ODD, Bipolar, etc.) (includes asthma, allergies, etc.) Other Medical Conditions Refer to CIC Core Team (includes AD/HD, CD, OCD, ODD, Bipolar, etc.) Temporary Disability: (Nature of disabling condition) General Education Homebound DESCRIBE THE NATURE OF THE MEDICAL/HEALTH CONCERN: BASIS FOR DETERMINATION OF NEED: (i.e. Child takes prescription medication on a daily basis, nurse has record of medical history on child, etc.) FOR TEMPORARY DISABILITIES: Approximately how long will the accommodation be needed? What is the approximate date for re-evaluation? (For all other health conditions, the student may be re-evaluated at any time during the year if problems are noted or reported by any staff.) WHICH OF THE FOLLOWING MAJOR LIFE ACTIVITIES IS OR MAY BE SUBSTANTIALLY LIMITED? Walking Hearing Learning (not slow learner) Communicating Talking Speaking Caring for one s self Major Bodily Function Seeing Breathing Performing manual tasks Reading Bending Sitting Eating Lifting Date screening notification to parents was made: By: (Name School Nurse) Notification made via: phone conference By: Date MED-1 sent to Campus RtI Coordinator or Campus 504 Coordinator : (Name School Nurse)
SECTION 504 MEDICAL INDIVIDUAL ACCOMMODATION PLAN MED-3 Student: ID #: DOB: Gr.: Campus: TYPE OF 504 PLAN: Date: Initial 504 Plan 504 Yearly Update 504 Revision 504 Temporary Disability DIRECTIONS: This plan is to be used for those Section 504 Medical Conditions, either temporary or long-term, and/or those medical conditions that may result in the student requiring General Education Homebound services. Plan must be individualized and specific. ADULT CONTACT(S): Name: Relationship to Student: Phone Number: Cell Number: MEDICAL CONDITION (describe): SPECIAL EQUIPMENT UTILIZED BY STUDENT: (describe): MEDICATION(S) ADMINISTERED (describe any side effects): ACCOMMODATIONS: (Include only those classroom/environmental adaptations and/or physical accommodations necessary to meet the individual needs of the student. Accommodations to be implemented must reflect what school personnel are going to do on behalf of the student not what the student is going to do. Examples: assistance with medication administration, inhalers, wheelchair accessibility, monitoring blood sugar, etc. Be specific.) 504 COMMITTEE MEMBERSHIP: List each member attending the 504 meeting and check the area of knowledge they provide. Each area of knowledge must be present on the committee. NAME/SIGNATURE POSITION/TITLE KNOWLEDGE OF Child Evaluation data Placement options Child Evaluation data Placement options Child Evaluation data Placement options Child Evaluation data Placement options
DOCTOR VERIFICATION OF NEED FOR HOMEBOUND INSTRUCTION MED-4 Student: DOB: ID#: Grade: Campus: Doctor s Name: Date of Physical Exam: Doctor s Address: Telephone #: YES NO 1. The student has a medical condition which will result in confinement to his/her home or hospital for a minimum of four (4) consecutive weeks. YES NO 2. Has this student been recommended for a follow-up exam? If YES, when? Approximate length of confinement: Diagnosis: Describe the nature of the condition(s) resulting in the need for homebound services: What is the criteria for the student returning to school? List recommendations for the school s reintegration plan including an approximate timeline for student s return. YES NO 1. Does the student have a communicable disease that poses a risk to the homebound teacher becoming infected or carrying it to another student? If YES, describe precautions that should be taken. YES NO 2. Is the student physically able to do school work with a homebound teacher? If NO, explain:
YES NO 3. Is the student permitted to participate in any activities outside the home? If YES, explain: YES N/A NO 4. If the student has not been totally confined to the home, is the student able to receive any instructional services on a general education campus (e.g., shortened school day)? If YES, explain: What medication is the student now taking? What effects, if any, will the medication(s) have on the student s learning? IF HOMEBOUND INSTRUCTION IS RECOMMENDED, PLEASE CHECK THE FOLLOWING: YES NO 1. This student is unable to function in the school setting, even for a shortened day at this time. YES NO 2. I recognize that homebound placement is a very restrictive educational placement that prevents the student from interacting with his/her peers. YES NO 3. My recommendation concerning educational placement is based on my professional medical evaluation of this student s condition. Signature of Licensed Physician Name (please print) Address Telephone Number City, State Zip Fax Number Return form to the campus 504 Coordinator: Completed form due no later than:
PLACEMENT CAMPUS COMMITTEE REVIEW MED-5 Student: ID #: DOB: Gr.: Campus: Any student who is served through the General Education Homebound (GEH) program must meet the following three criteria: 1. Student is expected to be confined at home or hospital bedside for a minimum of four consecutive or cumulative weeks; 2. Student is homebound for medical reasons only; and 3. Medical condition must be documented by a physician licensed to practice in the United States. (Completion of form MED-4 is required.) Name of Physician: Doctor s Office/Address: Medical Condition/Diagnosis: Approximate Length of Confinement: Based on the physician s note or letter, together with the GEH Committee s review of current evaluation data (including parent input, teacher/administrator input, grade reports, sample of student work, standardized tests and/or other tests as determined appropriate, etc.) the GEH Committee has determined that the student is: Eligible for Homebound Instruction: Yes No Type of Homebound Instruction: Home Hospital Bedside If Yes, please check ( ) the amount of time to be provided to the student per week: AMOUNT OF TIME TO BE PROVIDED EQUIVALENT SUBJECT AREA(S) One Hour per Week Two Hours per Week Three Hours per Week Four or More Hours per Week One day present Two days present Three days present Four days present Five days present
General Education Homebound services will be provided to the student in the following areas: YES NO Access to textbooks, assignments, projects, and tests for self-study in the following subject areas: YES NO Access to classroom teachers by phone in the following subject areas: YES NO Extended time for the completion of projects in the following subject areas: YES NO Access to educational software, distance learning, correspondence courses, or other on-line instruction. If Yes, detail services to be made available: YES NO Other: YES N/A NO Formal transition from General Education Homebound to the classroom. (If the GEH Committee believes that a formal transition period is required for the student s return to school, please detail the transition calendar and steps for implementation.) Certified General Education Teacher(s): NOTE: The teacher providing GEH instruction shall maintain a log of contact hours and other appropriate documentation of the provision of the required services. Homebound Services START Date: Homebound Services STOP Date: / 504 COMMITTEE MEMBERS: required at a minimum) (Principal, Teacher, Parent/Guardian Principal Signature Parent/Guardian Signature Teacher Signature Teacher Signature Teacher Signature Other Signature *For students found eligible under Section 504, F-9 must be completed indicating instructional accommodations to be implemented by the GEH teacher providing services to the student.
CLASSROOM TEACHER NOTIFICATION OF INSTRUCTION MED-6 Student: ID #: DOB: Gr.: Campus: Date: TEACHER: CLASS SUBJECT: SUBJECT: ENGLISH MATH SOCIAL STUDIES SCIENCE OTHER: OTHER: PLACEMENT IN IS FOR APPROXIMATELY: weeks. I acknowledge receipt of this notice for General Education Homebound Instruction for the above named student. I understand that I am responsible for providing assignments to the General Education Homebound Instruction teacher (name) on a weekly basis. I agree to provide all assignments to the assigned GEH teacher or designee (name) no later than (day and time) each week. I further understand that I will also be responsible for evaluating and monitoring the student s work while he/she is in the General Education Homebound Instruction Program. When student s work indicates a lack of expected progress, I understand that it is my responsibility to notify the GEH Committee and/or 504 Committee and to recommend a meeting to discuss and address the lack of appropriate progress. CLASSROOM TEACHER S SIGNATURE: DATE:
General Education Homebound (GEH) Information to Campus PEIMS Coordinator Campus On, (Date) (Student Name & ID #) will begin home instruction. Please advise your campus PEIMS data clerk to remove all Technology Class CTE classes from this student s record for the home instruction period. The CEHI teacher will inform you when the student re-enrolls and the CTE classes can be reinstated. Signature CEHI Teacher Signature Campus PEIMS Coordinator Date Cc: PEIMS Coordinator CEHI Teacher Campus Nurse CSHD Director CTE Director 11/01/10 GEH Form # 6-A (CTE Exit)
General Education Homebound (GEH) Information to Campus PEIMS Coordinator CTE Reinstatement Form On, was (Date) (Student Name & ID #) dismissed from the CEHI Program back to your campus. Please advise your campus PEIMS data clerk that CTE classes can be reinstated. Signature CEHI Teacher Signature Campus PEIMS Coordinator Date Cc: PEIMS Coordinator CEHI Teacher Campus Nurse CSHD Director CTE Director 11/01/10 GEH Form # 6-B (CTE RE-ENTRY)
PARENT NOTIFICATION OF GEH PLACEMENT AND HOME INSTRUCTION GUIDELINES MED-7 Student: ID #: DOB: Gr.: Campus: To: Parent(s) or Legal Guardian: The General Education Homebound Instruction program is designed to help students keep up with their school work during their absence from school due to a medical condition, in order that they may return to school in due time and continue in their regular educational program. In order to best serve the student during his/her absence from school, we require that the family provide for the following listed points: 1. Provide a quiet, isolated place for the GEH teacher and student to work. It is recommended that parents and other children do NOT enter the room during the instructional period. 2. An adult person (not sibling) must in the home during the instructional period. This would provide for taking care of the student s needs that may arise during the instructional period that are not of a teaching nature. 3. Have the student ready for his/her instructional period at the designated time in order to make the best possible use of the instructional period. Please ensure that: a. the student is bathed and fed; b. the instructional room is in order with a suitable desk or table on which to work with proper lighting; and c. books and supplies are ready to use. 4. Report sickness of the student, which would prohibit his/her working in a scheduled instructional period. In the case of an unexpected illness or an appointment arises and the student cannot participate in his/her school work, please notify your GEH instructional teacher at between 8:00 AM and 8:30 AM or before the scheduled visit. The teacher will notify you if he/she will be unable to come to your home. Please make arrangements to discuss anything with the GEH instructional teacher at a time other than during your child s instructional period. It is our foremost goal to have the student be successful during his/her absence from school. Thank you for your cooperation, and please feel free to call us at you. if we can be of further service to MCALLEN INDEPENDENT SCHOOL DISTRICT By:
PARENT/LEGAL GUARDIAN RECEIPT FOR NOTIFICATION OF GEH INSTRUCTIONAL SERVICES AND GUIDELINES MED-8 Student: ID #: DOB: Gr.: Campus: PARENT NAME: ADDRESS: I acknowledge receipt of the Parent Notification of GEH Placement and Home Instruction Guidelines. I understand that I am responsible for providing the following: 1. Provision of a quiet, isolated place for the GEH teacher and student to work. I will ensure that any other children at home do NOT enter the room during the instructional period. 2. An adult person (not sibling) will be in the home during the instructional period and will be available to take care of the student s needs that may arise during the instructional period that are not of a teaching nature. 3. The student will be ready for his/her instructional period at the designated time in order to make the best possible use of the instructional period. I will ensure that: a. the student has been bathed and fed. b. the instructional room is in order with a suitable desk or table on which to work with proper lighting. c. books and supplies are ready to use. 4. I will report sickness of the student that will prohibit his/her working in the scheduled instructional period. In the case of an unexpected illness or an appointment prohibiting the student from participating in his/her school work, I will notify the GEH instructional teacher at between 8:00 AM and 8:30 AM or before the scheduled visit. PARENT SIGNATURE: DATE:
PARENT/LEGAL GUARDIAN OR ADULT STUDENT REJECTION OF GEH INSTRUCTIONAL SERVICES MED-8A Student: ID #: DOB: Gr.: Campus: PARENT NAME: ADDRESS: I acknowledge receipt of the Parent Notification of GEH Placement and Home Instruction Guidelines. I hereby REJECT the provision of General Education Homebound Services. (initial) I hereby acknowledge that the following has been fully explained to me by the district in making my decision of rejection of acceptance of general education homebound services: 1. Compulsory school attendance is required for students who are at least six years of age and who has not yet reached the age of 18. TEC 25.085 (a); 2. A person who voluntarily enrolls in school or voluntarily attends school after the person s 18 th birthday shall attend school each school day for the entire period the program of instruction is offered. A school district may revoke for the remainder of the school the enrollment of a person who has more than five absences in a semester that are not excused under TEC 25.087 (temporary absences). TEC 25.085(e); 3. A student may not be given credit for a class unless the student is in attendance for at least 90 percent of the days the class is offered. TEC.092(a); and/or 4. Section 504 equal opportunity requirements have been fully explained and I have received a copy of the Parent s and Student s Rights Under Section 504. PARENT/LEGAL GUARDIAN/ADULT STUDENT SIGNATURE: DATE:
-TEACHER S DAILY HOMEBOUND INSTRUCTION LOG MED-9 DIRECTIONS: Complete one form for all students served each day. If the student is NOT seen, indicate the reason under Service Provided. The GEH teacher s homebound instruction log must be submitted to the campus attendance office on a weekly basis. If student is also 504, a copy must also be provided to the campus 504 coordinator. TEACHER: DATE: DEPARTURE FROM TIME TOTAL TIME SERVICE PROVIDED SIGNATURES Location: TO ARRIVE DEPART TOTAL TIME SERVICE PROVIDED PARENT SIGNATURE TEACHER SIGNATURE Student: ID#: Campus: Instruction Specify: Student: ID#: Campus: Instruction Specify: Student: ID#: Campus: Instruction Specify: Student: ID#: Campus: Instruction Specify: Student: ID#: Campus: Instruction Specify: 5-15
DOCTOR S MEDICAL RELEASE OR EXTENSION OF HOMEBOUND SERVICES MED-10 Date: Student s Name: Date of Birth: On (date), I authorized the above named student to receive General Education Homebound Services with an anticipated date of return to school set for: This form shall be considered as written notification that this patient has been under our care and: Requires an extension of General Education Homebound Services for at least another weeks. Revised Expected Date of Return: May immediately return to school on Additional Comments/Directions: Printed Name of Physician Signature of Physician Address of Physician: Phone Number: Fax Number: Return completed form to: 5-16
NOTIFICATION OF GEH STUDENTS REQUIRING BENCHMARK AND/OR TAKS TESTING MED-11 Date: The following student(s) are currently being served by General Education Homebound (GEH): 1. ID#: 2. ID#: 3. ID#: 4. ID#: 5. ID#: I will be able to test the following student: I will not be able to help with any of the above students because I will be testing another student. SIGNATURES: MISD Testing Coordinator GEH Teacher s Signature Date Date
PEIMS ENTRY FORM MED-12 Date: Campus: Student: DOB: ID#: Grade: General Education Homebound Instruction was initiated on: GEH Teacher: PEIMS GEH coding entered on: Date Telephone: by:. PEIMS Staff Signature Original: Campus PEIMS Coordinator CC: GEH Teacher
PEIMS EXIT FORM MED-13 Date: Campus: Student: DOB: ID#: Grade: The above named student is exiting General Education Homebound Instruction on: Exit Date He/She will be returning to their home campus on: GEH Teacher: PEIMS GEH coding entered on: Telephone: Date by:. PEIMS Staff Signature Original: Campus PEIMS Coordinator CC: GEH Teacher
INDIVIDUAL INTERVENTION PLAN AND THREE WEEK PROGRESS MONITORING LOG MED-14 Student: DOB: ID#: Grade: Campus: INITIAL MEETING DATE: IMPLEMENT GEH SERVICES: YES NO LENGTH OF TIME NEEDED: COMMITTEE MEMBERS: SERVICES TO BE PROVIDED (List special provisions): ELA: MATH SOCIAL STUDIES: SCIENCE OTHER: ADDITIONAL COMMENTS: MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS: MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS:
MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS: MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS: MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS: MONITORING DATE: COMMITTEE MEMBERS: ACADEMIC PROGRESS: SATISFACTORY UNSATISFACTORY GRADES TO DATE: ELA: MATH: SOCIAL STUDIES: SCIENCE: OTHER: CONTINUE GEH SERVICES: YES NO ADDITIONAL COMMENTS:
CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION MED-15 Student: ID #: DOB: Gr.: Campus: Date: The McAllen Independent School District requests that you authorize the person or agency named below to release specified records containing confidential information regarding the above named student. AGENCY/PROGRAM TO WHOM REQUEST IS MADE: NAME OF PERSON TO WHOM REQUEST IS MADE: ADDRESS: PHONE #: CITY/STATE: FAX #: NAME OF PERSON OR ORGANIZATION TO WHOM DISCLOSURE IS TO BE MADE: RECORDS REQUESTED: Referral Summary of Assessment Psychological/Psychiatric Evaluation Medical Evaluation Individual Accommodation Plan Other: PURPOSE OF DISCLOSURE: To help determine: The most appropriate services for this student. Necessity for additional testing. Other: Please check (X) the Yes box only if you agree that the statements are correct. If the statements are NOT correct, check the No box. If you wish to have more information or if you have any questions, call: (School Staff Person) at (Telephone Number). YES NO I have been fully informed and do understand the school s request for my consent of release of my child s records, as described above. This information will be released upon receipt of my written consent. I also understand that my child s records are protected under the Federal regulations in the Family Education Rights and Privacy Act (FERPA), and/or the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R., Part 2, and cannot be disclosed without my express written consent unless otherwise provided for in the applicable regulations.
YES NO I understand that my consent is voluntary and may be revoked in writing at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically on: Signature of Parent, Surrogate Parent, Legal Guardian or Adult Student Date Signature of Interpreter None Needed Date
FOLDER CHECKLIST MED-16 Student: ID #: DOB: Gr.: Campus: DIRECTIONS: Use this form as the cover sheet and checklist to ensure that each GEH folder is complete. If it is determined that the student is also eligible for Section 504 (Temporary Medical Condition), refer to Section 4 of the 504 manual for the additional required forms. As each form is completed, the individual completing the form must initial the checklist. REQUIRED FORM: MED-4, Doctor Verification of Need for Homebound Instruction MED-5, GEH Placement Campus Committee Review MED-14 or F-9, Individual Intervention Plan or Individual Accommodation Plan (circle which used) MED-6, Teacher Notification of GEH Instruction MED-8, Parent Receipt for Notification of GEH Instructional Services and Guidelines MED-10, Doctor s Medical Release or Extension of Homebound Services MED-11, Notification of GEH Student Requiring Benchmark and/or TAKS Testing MED-12, PEIMS Entry Form MED-13, PEIMS Exit Form MED-15, Consent for Release of Confidential Information Section 504 Forms as required Refer to Section 4 of manual ATTACHED (CHECK) COMPLETED (INITIAL)