WARWICKSHIRE Flexible Learning Team

Request for Support of Pupil Absent Because Of Ill Health

Notes for guidance:

Please refer to the county policy for children with health needs before completing this form.

  • All forms must be completed in full and have supporting medical advice on the form provided.
  • Requests cannot be accepted until all the completed information including medical authorisation is received by The Flexible Learning Team.
  • Schools will be contacted to request the completion of the necessary information before provision can be considered.
  • The Flexible Learning service is available to all pupils resident within Warwickshire and remains a part centrally funded local authority service, currently available free of charge at point of delivery for the first 6 weeks of referral, supported by 80% Key Stage AWPU funding charged weekly for the remainder of any period of support, schools will be invoiced at the end of each half term.

CHECKLIST

Please complete and ensure that the following documentation accompanies the Request for Support:

The Flexible Learning Team Medical information Form attached in support of Request for Support (please tick)

SATs results/baseline assessment information attached (please tick)

Copies of Statement/IEP’s attached, as appropriate (please tick)

Attendance dataprintout

WARWICKSHIRE Flexible Learning Team

Request for Support of Pupil Absent Because Of Ill HealthJanuary 2017

ALL SECTIONS OF THIS REQUEST FOR SUPPORT FORM MUST BE COMPLETED IN FULL

Permission must be obtained before submitting your Request for Support by asking the parent/guardian to sign the consent form below and the The Flexible Learning TeamRequest For Medical Information (page 3/4), in order for:
  • The Flexible Learning Team to make initial contact with the family
  • The Flexible Learning Teamto receive health information concerning a pupil’s absence
  • TheSchoolto contact the family every term to request up to date medical information concerning a pupil’s continued absence
Please note that out of date or incomplete forms cannot be accepted
Signed: Parent / Guardian:Date:

On behalf of School: Date:
I understand that the service is core funded for 6 weeks and that the school will be invoiced from week 7 of any referral. Please see ‘advice for schools’ section on our website.
Position in school:
Personal Details

Pupil: UPN:

D.O.B.: NCYr:Gender:
Parent/carer details
contact 1: contact 2:
Address: Address:
Contact number(s) Contact number(s)

Email address: Email address:
School Details

Referring school:

Designated school contact and role in school:

Tel: Fax: E-mail:__
Absence Details
Please detail any support via outside agency involvement (e.g. ACE /CAF/CAMHSetc) received prior to Request for Support

Current Diagnosis causing absence from school?

What is likely to trigger or maintain continued absence causing the need for Support from the Flexible LearningTeam?

Please list the KEY OBJECTIVES of yourrequest for Flexible Learning Team support:

Proposed timescale for reintegration/transition from Flexible Learning Team support back to school or elsewhere:
Date absence began?

When has work been sent home? (please supply dates)

Does the student have a statement/EHCPlan? If yes please ATTACH

Has an assessment for EHCP been requested?

Does the pupil have an IEP? If yes please ATTACH copy of the IEP

Does the student have a confirmed diagnosis of ASD?
Please complete the following (as applicable) including address and telephone number.
It is ESSENTIAL that medical information pages(3 and 4) aresigned by the parent/guardian and included in support of your Request after completion by one of the following:

Consultant / Hospital Doctor:

GP:

CONFIDENTIAL

WarwickshireFlexible Learning Team - Request for Medical Information

This form should be completed by the relevant Consultant or GP involved

In order for the Flexible Learning Team to plan appropriate education provision for pupils we need to receive detailed information regarding their medical condition. Permission to request this information has been given by:

Signed:______Parent/carer.

Pupil Name: ______Pupil DOB:______

Name of School: ______

Please complete this form in full and return it as soon as possible to the address overleaf.

Current medical reason for absence from school:

Most recent appointment:

Intervention/medication/support currently being offered:

Timescale for current intervention to continue:

Prognosis /Plan for future intervention:

Next appointment:

Next treatment review:

Effect this condition is having on access to education:

Given patient history/current condition I advise that this pupil (please tick)

  • Should not be in school at the present time
(Subject to 6 weekly review toward reintegration)
  • Should be able to attend a reduced school timetable
  • Should be able to attend offsite provision with support

  • Is well enough to attend school full time at present

Additional information (e.g. previous medical history/issues affecting education /attendance):

Please return this form directly to the Flexible Learning Team office by post to:

Education & Learning

Oakfield Park

32 Bilton Road

Rugby

CV22 7AL

Data Protection Statement

Your information rights

To see how we use your personal data and what your information rights are, please read our overall customer privacy notice at which includes the contact details if you have a complaint about your information rights. For general enquiries, contact Warwickshire County Council customer services on 01926 410410.

Academic Information *Requiredbefore support can begin*

KS2 Teacher Assessments

These are the student’s results for the Statutory end of KS2 assessments:
Reading / _____ / Using and applying maths / _____ / Experimental and investigative science / _____
Writing / _____ / Number and algebra / _____ / Life processes and living things / _____
Speaking and Listening / _____ / Shape, space and measure / _____ / Materials and their properties / _____
Handling data / _____ / Physical processes / _____
English Subject Level / _____ / Maths Subject Level / _____ / Science Subject Level / _____

KS2 Assessment Information

These are the student’s results for the Statutory KS2 Tests:
Reading level / _____ / Mental Maths Score / _____ / Test A Score / _____
Writing level / _____ / Test A Score / _____ / Test B Score / _____
Test B Score / _____
English Subject Level / _____ / Maths Subject Level / _____ / Science Subject Level / _____

KS4 Qualifications Studied

Curriculum Information

English Language board
e.g. AQA 8700 / What (if any) set texts would you like the student to read?
Materials can be emailed to:
English Literature board
e.g. AQA 8702
Contact in the English department
NB: If the student is to be entered for English Literature GCSE, please ensure that they are provided with appropriate texts, controlled assessment materials and revision materials so that they can self-study at home.
Mathematics board / Tier of Entry
(Foundation or Higher)
Materials can be emailed to:
Contact in the Maths department
Computing board
units/modules/tasks / Materials can be emailed to:
Contact in the Computing
Department
ICT board
Please include options/modules
chosen / Materials can be emailed to:
Please note that without the information below, the student will be registered for the Foundation level combined science lessons on line. The most appropriate class (H or F) will be decided once their ability has been assessed.
Science / Examination board and examination code / Target (T) grade (and/or) Predicted (P) grade / Likely tier of entry
Any other information / comments
Your contact in the science department :
Materials can be emailed to:

Data Protection Statement

Your information rights

To see how we use your personal data and what your information rights are, please read our overall customer privacy notice at which includes the contact details if you have a complaint about your information rights. For general enquiries, contact Warwickshire County Council customer services on 01926 410410.

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