Home/Hospital Instruction

Home/Hospital Instruction

Revised 7-6-10 Page 1 of 2

New Hanover County Schools

Home/Hospital Instructional Services

Physician’s or Appropriately Trained and/or LicensedHealth Professional’sStatement

and

Consent for Mutual Exchange of Information

Home/Hospital instruction is being considered for the student whose name appears below. Medical advice is necessary in determining whether or not the student is eligible for Home/Hospital Instruction.

To Be Completed by Parent/Guardian (Prior to being given to Physician or Appropriately Trained and/or LicensedHealthProfessional):

Name of Student______Grade______DOB______

School______Phone: ______Fax:______

School Address______

Parent/Guardian(s)______

Address ______

Phone: Home: ______Cell: ______Other/Alternate: ______

Parent Consent for Release of Medical/Psychological Information

New Hanover County Schools has my permission to receive medical information from the attending physician or other appropriately trained and/or licensed health professionals for my child in order to deliver home/hospital service.

(Parent/Guardian/Student at Age of Majority) Signature: ______Date:______

To Be Completed by Physician orAppropriately Trained and/or Licensed Health Professional):

1. Date of Last Examination: ______

2. Medical:

  • Is student free from communicable disease? ______
  • Type of illness or disability______
  • Can student attend school with special accommodations? ______Yes ______Does Not Require Accommodations.

If yes, list or describe accommodations.(i.e.modified school day, access to elevator, assisted movement between classes, peer assistance with carrying books, etc.)

______

3. Psychological: (Complete this section only if applicable)

Treatment/Counseling Professional (Print name):______

Title: ______Phone: ______

Diagnosis: ______

Revised 7-6-10Page 2 of 2

  • Describe any potential impact of this diagnosis or treatment, on the student’s performing of school assignments: (Include information about cognition, concentration, attention, alertness, impact on strength and physical level.
  • List or describe any behaviors associated with this associated with this condition that may adversely affect this student in an educational setting.
  • Can this student attend with a modified schedule?
  • What is the treatment plan (i.e. therapy sessions, medications)?

4. Pregnant Students: (Complete this section only if applicable)

  • Number of weeks recommended for school absence: ______
  • PLEASE INDICATE THE PRE-TERM CONDITION THAT HAS BEEN DIAGNOSED. FOUR WEEKS POST-PARTUM AVAILABLE TO ALL PREGNANT STUDENTS

___ Pre-Eclampsia___ Polyhydramnios___ Diabetes Mellitus___ Pre-term Labor___ Bleeding

___ Incompetent Cervix ___ Cesarean Section (4 weeks) ___ Pre-mature Delivery ___ Young age (14 or younger)

___ Other

  • How do the medical complications listed above support the amount of recommended school absence:

______

5. Recommendations:

Why is Home/Hospital instruction recommended?

______

______

Estimated length of time student will require home or hospital services?______

NOTE: Periodic medical updates may be required to support extended services. For services due to psychological diagnosis this information must be updated every 4 to 6 weeks.

Physician’s/Appropriately Trained and/or LicensedHealth Professional’s name (print or type):

______

Signature of Physician/Appropriately Trained and/or LicensedHealth Professional:

______

Address______Date______

Phone number ______FAX number ______

(Please keep a copy of this form with patient’s record)

Please return this form to the student’s school listed on the first page.

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