Calhoun City Schools 380 Barrett Rd. Calhoun, GA Fax: (706) Program Supervisor (706)

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1 Calhoun City Schools 380 Barrett Rd. Calhoun, GA Fax: (706) Program Supervisor (706)

2 Table of Contents General Information Hospital/Homebound Personnel Contacts 2 Rationale and Purpose Statement 3 Mission Statement 3 Guidelines and Procedures 4-6 Hospital/Homebound Instruction State Board Regulations 6-9 About Our Services 9-11 Individual Procedures for: The Hospital/Homebound Teacher 11 The Classroom Teacher The Licensed Physician 12 The Parent and Child 12 The School s Contact Person FORMS Referral Form Teacher Correspondence Log 16 Monthly Teacher Report 17 Classroom Teacher Assignment Sheet 18 Parent Contact Information 19 Weekly Progress Report Form 20 Intake Meeting Form 21 Re-entry/ End Services Form 22 RESOURCES Parent Survey Form 23 Internet Resources for Homework Help 24 1

3 Hospital/Homebound Personnel Contacts Central Office Bob Orfield Special Education Director Phone ( ) Schools Calhoun Primary School Calhoun Elementary School Mana Smith Kelli Kendrick Assistant Principal Intervention Specialist Calhoun Middle School Calhoun High School Josh McCanless Ray Reece Assistant Principal Assistant Principal

4 Rationale and Purpose Statement The purpose of this Hospital/Homebound Manual is to serve as a general resource guide regarding students and the procedures to be used when there is a need for an instructional program for a student who has: a medically diagnosed condition as determined by a licensed physician. restricted to home or hospital (in accordance with state regulation ) School level personnel should continue to consult with the Director of Special Education with regards to specific questions or situations which may arise as a result of Hospital/Homebound services. Mission Statement The Hospital/Homebound program is designed to provide an academic bridge in partnership with the base school to students that meet State guidelines as they recover from their illnesses, so that they can continue to receive educational benefit. We Believe all children are unique and capable of learning. that given appropriate accommodations students can continue to learn while recovering from illnesses that have interrupted the educational routine. by partnering with the base school educational programs can be implemented so that a students educational needs can be met. each student has individual learning styles and needs that should be addressed in the learning process. the student is the most important person in school and it is our responsibility to provide learning experiences appropriate to meet individual needs. 3

5 Hospital/Homebound Guidelines and Procedures Please review the information below. Any questions should be directed to the Director of Special Education at the Central Office. Summary of Services Hospital/Homebound services offer a short-term instructional program for students who are anticipated to be absent for 10 or more school days and are confined to home or hospital by a medically diagnosed physical or mental condition. The program may also be utilized if a licensed physician certifies that a student has a chronic health condition causing him/her to be absent for intermittent periods of time during the school year. Students with chronic health conditions should be in the Student Support Team process and have either a SST plan, a 504 plan or in certain circumstances be considered for a referral to Special Education. Objective Hospital/Homebound teachers will provide modified academic instruction that enables the student to keep up with their academic responsibilities while at home, thus allowing the student to return to his/her regular school program with as little interruption as possible in academic instruction. Goal It is the goal of the Hospital/Homebound staff to work closely with the family and the student s base school in order to facilitate a smooth, successful transition for the student upon returning to a regular school program. Non-Covered Conditions Suspensions Expulsions Pregnancy Normal pregnancy and/or birth do not generally qualify for services. However, if there are abnormal restrictions from activities as prescribed by a licensed physician where the mother s health or the unborn child s health are in jeopardy or a complicated birth affecting the mother hospital/homebound services may be granted. This is considered on a case by case basis. Communicable diseases except as specified in Rule Questions regarding non-covered conditions should be directed to the director of Special Education Attendance Status: Students are NOT counted absent as long as they receive three (3) hours of weekly instruction. This is not retro active and can only take place after a proper referral is received, has been approved and services have been delivered. Communication with attendance clerks is critical to insure accurate reporting of attendance data. Extra Curricular Activities In general by definition student s receiving hospital/homebound instruction are unable to attend school. Therefore, by default are not eligible to participate in school related extra curricular activities. In rare situations there are exceptions to this guidance. For example in the case of a student diagnosed and receiving services for agoraphobia (an extreme anxiety disorder) it may be appropriate for this student to attempt to access school by attending an extra curricular activity or a class as a part of the therapeutic process. The building Principal (or designee), Director of Special Education, Parent, Student and treating Physician will collaborate on situations such as this. 4

6 Chronic or Recurring Medical Conditions Some medical conditions that are chronic in nature adversely impact typical educational programming by causing the student to be absent for school on a sporadic basis requiring intermittent Hospital Homebound procedures. Eligibility/Procedures Please note the following eligibility requirements and procedures for obtaining Hospital/Homebound instruction. 1. The student must be enrolled in a Calhoun City school prior to the referral to the Hospital/Homebound program. 2. Parent/Guardian or student contacts school officials to discuss the need for Hospital/Homebound services due to circumstances that lead to extended absence or a chronic qualified health condition. 3. School officials review the request and determine if a Hospital/Homebound referral form should be issued. o School officials should consider all available options prior to issuing a Hospital/Homebound referral. 4. Parent/Guardian or student takes the Hospital/Homebound referral form to a licensed physician to be completed. 5. Physician completes referral. o o The physician should specifically state the nature of the illness, the projected length of absence (anticipated to be absent for 10 or more school days) and that the student is physically able to participate in Hospital/Homebound instruction. The physician s signature is required. 6. Parent completes their portion of the referral. 7. Hospital/Homebound referral is returned to the base school. Principal reviews the referral for accuracy and completeness prior to signing-off. 8. Referral is forwarded to the Central Office. o The information will then be reviewed and confirmed with the physician s office, if necessary. 9. Base school assists in locating a teacher willing to provide the Hospital/Homebound services. 10. A student is eligible for Hospital/Homebound educational services after submitting a medical referral form to the local school completed and signed by a licensed physician, as well as the parent or guardian. 11. An IEP meeting must be convened to determine the needs of special needs students that are found eligible for hospital/homebound services. 12. Students are not eligible for Hospital/Homebound instructional services if their absence is due to communicable disease, except as specified in state board policy JGCC (Communicable Diseases). 13. Students will not receive services for pregnancy unless there are abnormal restrictions from activities as prescribed by a licensed physician. Services will be provided, 5

7 however, if such services are specified in the individualized education program (IEP) of a disabled student. 14. Re-documentation of a chronic or recurring condition is not required but may be requested by the program coordinator. 15. While receiving Hospital/Homebound instruction, a student will be counted present for the week, when a minimum of three hours of services are delivered within the week. 16. Classroom teachers will be responsible for providing lesson plans, assignments, necessary materials (including textbooks), and exams. Please keep in mind that these students are ill and work should be modified appropriately. 17. The Hospital/Homebound teacher will contact the parent and arrange a mutually agreed upon time for the instructional services each week. o o o A Hospital/Homebound informational packet will be given to the parent or guardian regarding the procedures and guidelines of the program. NOTE: In addition to the Hospital/Homebound teacher, an adult must be present during each entire home instructional period. In the case where an adult is not present, the Hospital/Homebound teacher will document this and leave the premises. If a child is physically able to complete work, but does not do so after a threeweek period, services may be discontinued. 18. The Hospital/Homebound teacher will notify the school when the student is ready to return to school. If necessary a Re-entry meeting will be scheduled with appropriate stakeholders to discuss student needs. State Regulations for Hospital/Homebound in Georgia Code: IDDC HOSPITAL/HOMEBOUND (HHB) SERVICES. (1) DEFINITIONS. (a) Adult Parent Designee an individual who is at least 21 years of age and who the parent designates to be present during homebound instruction. (b) Chronic Health Condition a medical condition marked by a long duration or frequent recurrence. (c) Educational Service Plan (ESP) an individual plan for students receiving HHB service developed by the local school team, to include a school reentry procedure. The plan may include accommodations and modifications from a Section 504 plan, or Individualized Education Program (IEP), as applicable. (d) Hospital/Homebound (HHB) Services academic instruction and other services provided to eligible students who are confined at home or in a health care facility for periods of time that would prevent normal school attendance based upon certification of need by the licensed physician or licensed psychiatrist who is treating the student for the presenting diagnosis. (e) Instruction the teaching of standards as defined by Georgia Performance Standards (GPS), the Georgia Quality Core Curriculum (QCC), Section 504 plan, IEP, and any local curriculum for the classes in which the HHB student is enrolled and under the direction of the classroom teacher(s). (f) Intermittent HHB Service HHB instruction and other services for eligible students who have a medically diagnosed chronic health condition which may cause the student to be absent at least a total of 10 school days for intermittent periods per year or equivalent on a modified calendar or five school days per year on a high school block schedule. 6

8 (g) Licensed Physician a person licensed to practice medicine under state law O.C.G.A and licensed by the appropriate state board to assess the student s physical condition forwhich the student is referred. (h) Licensed Psychiatrist a person licensed to practice medicine under state law O.C.G.A and trained to practice in the science of treating mental diseases to assess the student s psychiatric and/or emotional condition for which the student is referred. (i) Long-term HHB Service HHB instruction and other services for eligible students who have a medically diagnosed chronic health condition which may cause the student to be absent from school for more than nine consecutive weeks per year or equivalent on a modified calendar. (j) Online Learning Course a State Board of Education-approved course of instruction directly correlated to the state-approved curriculum that is delivered via the Internet or in any electronic medium. (k) School Day a day as specified by the local board of education which is the period between the time students are required to be present and their dismissal ( SCHOOL DAY FOR STUDENTS); ten school days on a regular high school schedule (six 50- minute classes per day) is equivalent to five school days on a high school block schedule. (l) Temporary HHB Service HHB instruction and other services for eligible students who have a medically diagnosed physical or psychiatric condition, which confines the student to home or hospital and restricts activities for nine weeks or less, but for a minimum of ten consecutive school days or equivalent on a modified calendar or a minimum of five consecutive days on a high school block schedule. (2) STUDENT ELIGIBILITY. (a) The local education agency (LEA) shall provide HHB services to students, including students with disabilities, who meet the following eligibility requirements: 1. The student is enrolled in a public school prior to the referral for HHB services. 2. The student must be anticipated to be absent for a minimum of ten consecutive school days per year or the equivalent on a modified calendar or the student has a chronic health condition causing him or her to be absent for intermittent periods of time anticipated at a minimum of ten school days per year or equivalent on a modified calendar or five school days on a high school block schedule per year. (i) A student with a chronic health condition receiving intermittent HHB service must be anticipated to be absent for at least three consecutive school days for each occurrence before he or she will be eligible for HHB services. 3. The parent or guardian must sign the parental agreement concerning HHB policies and procedures, and parental cooperation. A release for medical information relating to the reason for the request for HHB service may be required by the LEA. (i) If the student is designated as an emancipated minor or is 18 years of age or older, that student is eligible to sign the parental agreement concerning HHB policies and procedures, parental cooperation, and release for medical information relating to the reason for the request for HHB services. 4. The LEA must receive a completed medical referral form signed by a licensed physician or licensed psychiatrist who is currently treating the student for the diagnosis presented. A statement from a treating specialist may also be required. (i) The medical referral form shall contain a statement that includes the following information: (I) That the student is anticipated to be absent for a minimum of ten consecutive school days per year due to the relating documented medical condition or equivalent on a modified calendar (or five consecutive school days on a high school block schedule); or (II) That the student with chronic and long-term illnesses will be absent for at least ten school days or equivalent on a modified calendar (or five school days on a high school block schedule) 7

9 which need not run consecutively; and (III) That the student is able to participate in and benefit from an instructional program; and (IV) That the student can receive instruction without endangering the health and safety of the instructor or other students with whom the instructor may come in contact; and (V) That describes the disabling condition or diagnosis with any medical implications for instructional services. (ii) The medical referral form for a student with chronic or recurring conditions and long-term illnesses shall be obtained and updated on a schedule defined within the ESP and submitted to the LEA. (b) Students with absences due to psychiatric and/or emotional disorders, as defined in the latest edition of the Diagnostic and Statistical Manual (DSM), are eligible for HHB services for a length of time as determined by the ESP provided that they satisfy the eligibility requirements as set forth in Subsection (2)(a). (c) Students with absences due to pregnancy; related medical conditions, services, or treatment; childbirth; and recovery there from are eligible for HHB services for a length of time as determined by the ESP provided that they satisfy the eligibility requirements as set forth in Subsection (2)(a). [Title IX, 34 C.F.R (b)(4).] (d) Students with absences due to a communicable disease, as specified in Rule COMMUNICABLE DISEASES, are eligible for HHB services for a length of time as determined by the ESP provided that they satisfy the eligibility requirements as set forth in Subsection (2)(a). INITIATION OF HHB SERVICES. (a) The LEA may require the parent, guardian, emancipated minor or student who is 18 years of age or older to provide a properly signed release that complies with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) that authorizes the licensed physician or licensed psychiatrist who is treating the student to provide all requested records related to the conditio n related to the request for HHB services to the LEA and to discuss the student s situation and the need for HHB services with the school team. If the release is required by the LEA, the form must be provided to the school team prior to any decision regarding the need for HHB services. (b) A completed written medical referral form requesting HHB services must be submitted to the LEA for HHB services to be considered. (c) The request will be forwarded to the appropriate local school team designee or IEP team, whichever is appropriate, to assist in the development of an ESP to deliver the appropriate HHB services. The ESP shall include a school re-entry plan. The school team shall use input from the medical referral form completed by the referring licensed physician or licensed psychiatrist who is treating the student for the diagnosis presented. The appropriate local school designee or IEP team responsible for the development of the ESP may consider requests for extensions. (d) Within five school days of receiving the completed medical referral form, the LEA shall provide written notification of the time and place of the local school team meeting, if for general education students, or the IEP meeting, if for students with disabilities, regarding HHB services. (4) HHB INSTRUCTION. (a) HHB instruction shall be provided by a certified teacher, who is selected by the LEA in which the student is enrolled. Students eligible for services under the Individuals with Disabilities Education Act (IDEA) shall be served by appropriately certified personnel. (b) HHB instruction may be offered, individually or in small groups, at the home of the student, the health care facility in which the student is confined, through online learning courses, or at other locations as identified in the ESP. The type of HHB instruction offered is based on the ESP which takes into consideration the cognitive ability and medical condition of the student. 1. To provide HHB instruction to a student confined in a health care facility, the LEA in which the student is enrolled shall arrange with or contract directly with the health care facility, the LEA in which the health care facility is located, or the appropriately certified teachers in the geographic area in which the health care facility is located. (c) Although the local school team or IEP team shall determine the number of hours necessary to meet the instructional needs of the student, the student must receive at a minimum three hours of HHB instruction per school week to be considered present by the school. 8

10 1. A parent, guardian, or an approved adult parent designee as identified in the ESP shall be present during each entire home instructional period in which an HHB instructor is present. 2. If the student is designated as an emancipated minor or is eighteen years of age or older, an approved adult parent designees presence is not required during each home instructional period in which an HHB instructor is present. 3. If the student is unable to receive a scheduled HHB instructional session during the school week due to his or her medical condition as documented by the licensed physician or licensed psychiatrist who is treating the student for the diagnosis for which he/she is receiving HHB services, a make- up instructional session may be provided. Once the student completes the makeup instructional session, the student shall be counted in accordance with Rule Student Attendance. 4. If the parent, guardian, or the approved adult parent designee of the student cancels a scheduled HHB instructional session, the student shall be counted absent. The LEA may reschedule the canceled session. 5. Students confined in a health care facility shall be counted present if the health care facility submits a HHB Verification of Instruction form to the LEA HHB designee. (d) HHB students must participate in required state assessments as determined by the ESP or IEP. The appropriate local school team or IEP team shall develop strategies to ensure the delivery of these assessments services. If the student is medically able according to the licensed physician treating the student for the diagnosis for which he/she request HHB service, the student shall take the assessment in the school in which he or she is enrolled. Authority O.C.G.A ; , ; Adopted: November 4, 2009 Effective: November 24, 2009 About our Services: Generally Non-Covered Conditions Suspensions, Expulsions, Pregnancy, Contagious Illnesses We provide approximately 3 hours of instruction per week. We provide contact between the school, the home, and the medical community. We take the work to students and return completed work to the school. We can often work with Intermittent students at school after a period of absences in order to help them catch up on their assignments. They are often too ill to work when they are out of school. We try to take them out of connections-type classes in order to work with them. We can attend SST meetings, IEP meetings, planning meetings, and parent conferences if you need our input. We can't cover all subjects. We concentrate on academics. Elementary: Math & Reading Middle & High: Math, Reading, Language Arts, Social Studies, & Science There are 2 types of Hospital/Homebound services: Regular H/H and Intermittent H/H. Regular Homebound Service For students that are anticipated to be out of school for 10 or more school day due to accident, surgery, etc. **You do NOT have to wait until they have missed 10 days to make application A Homebound form is required in order to place a student in this program. (Principal must sign) 9

11 The parents complete agreement form (Includes the medical release -- VERY IMPORTANT!) The physician completes the last portion of the referral. The physician that is actually treating the condition must complete it. The form is returned to us for review and investigation. If everything is accurate and the diagnosis is a covered condition, then the form will be approved. We notify the school and request work from teachers. ** If the student is absent beyond the originally anticipated time, an extension from the physician is required. It can't be extended based on the parent's request alone. Intermittent Homebound Students with chronic illnesses such as cancer, cystic fibrosis, etc. that require intermittent absences may be placed in this program. Forms required: The Regular Homebound Form form completed by the physician ** At a minimum, an annual medical update is required for chronic conditions. Calhoun City Schools may request medical documentation in addition to the H/H referral forms for Intermittent H/H students out of school for periods of 10 consecutive days or more, or for fewer periods of consecutive absences if additional voluntary H/H services are being pursued as outlined in the student's IEP, IAP, SST Plan, or 504 Plan. Absences How does having a student on Homebound affect absences? Students are NOT counted absent as long as they receive 3 hours of weekly instruction. Regular Homebound students Upon a students return to school, you will receive an attendance record sheet. As long as the student participated in the homebound program, you will be asked to count them present for the covered H/H period If they partially participated in the program, the dates for which you can count them present will be indicated If they did not participate in the program, you will be asked to count them absent Intermittent Homebound Students At the end of the school year, you will be sent the same attendance record sheet. Special Situations Students with mental/emotional problems are NOT automatically placed in the Hospital/Homebound program upon receipt of a referral. A Student Support Team is formed and a meeting must be held. Often, a better plan can be put in place. Most of the mental health physicians in town prefer an option that doesn't require the student to be taken completely out of school. We always try to meet with the referring physician to get their input into the planning process We can provide support services during transitions Special Education Students referred for homebound services must have an IEP addendum written BEFORE services can begin. This usually requires an IEP meeting. 10

12 It is possible for students in out-of-town hospitals to receive H/H services during their hospitalization. Scottish-Rite, Shriners' Hospitals, and some of the psychiatric facilities have on-staff teachers that work with us. We can assist you in contacting them. Don't hesitate to go ahead and send work with the student if you know about the hospitalization ahead of time. We provide approximately 3 hours of instruction per week. We provide contact between the school, the home, and the medical community. We take the work to students and return completed work to the school. We can often work with Intermittent students at school after a period of absences in order to help them catch up on their assignments. They are often too ill to work when they are out of school. We try to take them out of connections-type classes in order to work with them. We can attend SST meetings, IEP meetings, planning meetings, and parent conferences if you need our input. We can't cover all subjects. We concentrate on academics. Elementary: Math & Reading Middle & High: Math, Reading, Language Arts, Social Studies, & Science Hospital/Homebound Procedures for the Hospital/Homebound Teacher 1. The Hospital/Homebound teacher will contact the parent/guardian in a timely manner to schedule a weekly appointment for Hospital/Homebound instruction. 2. The Hospital/Homebound teacher will collect the student s work from the office on a designated day and provide instruction for this student on a weekly basis. Minimum of 3 hours weekly. 3. The Hospital/Homebound teacher will provide instruction with integrity and fidelity. 4. The Hospital/Homebound teacher will send progress reports with completed work to each teacher weekly. 5. The Hospital/Homebound teacher will communicate concerns from the student or family to school personnel. 6. The Hospital/Homebound teacher will notify the school when the student is ready to return to school. If necessary a Re-entry meeting will be scheduled with appropriate stakeholders to discuss student needs. 7. Statewide Assessments If necessary and allowed by assessment procedures State Assessments may be administered in the Hospital/Homebound setting. All test security measures and ethic considerations must be adhered to. Coordinate with these efforts with the building Principal, Director of Special Education and Assessment Coordinator. Hospital/Homebound Procedures for the Classroom Teacher 1. The student s academic needs remain the classroom teacher s responsibility. 2. The classroom teacher should review Hospital/Homebound guidelines and the initial referral to gain an understanding of the student s needs. 3. The classroom teacher should prepare all missed and current work, books, and materials needed for the Hospital/Homebound student to the Hospital/Homebound teacher on a weekly basis. It is helpful to keep a folder in the classroom for the child s work. 4. The classroom teacher will prioritize assignments due to limited amount of weekly instructional time. According to the Hospital/Homebound guidelines and procedures, a student s work can and should be modified. For example, if the students in the classroom complete 50 math practice problems, the homebound student should be allowed to complete 25 of the problems if the concept is shown to be mastered. Remember, Hospital/Homebound students are ill, and service time is somewhat limited. 11

13 5. The classroom teacher will notify the Hospital/Homebound teacher of any concerns, questions, failures, or problems immediately. 6. The classroom teacher will send back graded work/feedback on a timely basis. Progress reports and/or report cards are to be sent to the Hospital/Homebound student at the same time that they are issued to classroom students. This enables the student and Hospital/Homebound teacher to gauge progress and/or assess problem areas in a timely manner. 7. The classroom teacher will attend a Re-entry meeting if scheduled. Hospital/Homebound Procedures for The Licensed Physician Physician completes referral. o o The physician should specifically state the nature of the illness, the projected length of absence (anticipated to be absent for 10 or more school days) and that the student is physically able to participate in Hospital/Homebound instruction. The physician s signature is required. A licensed physician must certify that the student is expected to be absent from school due to a physical or mental condition, or due to a repeated intermittent chronic condition, for at least 10 school days and will be able to participate and benefit from an instructional program. The student is under medical care for the illness, which may be acute or chronic in nature. The physician must certify that the student can receive instruction without endangering the health of the instructor or other students with whom the instructor may come in contact. Students are not eligible for Hospital/Homebound instructional services if their absence is due to communicable disease, except as specified in state board policy JGCC (Communicable Diseases). Hospital/Homebound Procedures for The Parent and Child Parent/Guardian or student should contact school officials to discuss the need for Hospital/Homebound services due to circumstances that lead to extended absence or a chronic qualified health condition. Parent/Guardian or student takes the Hospital/Homebound referral form to a licensed physician to be completed. Parent completes their portion of the referral. After the parental and physician sections of the referral form are completed, the form should be returned to the school for the principal to review and sign. An adult shall be present during each entire home instructional period, except where instruction is provided through telecommunication devices. Instruction may be offered in home or hospital settings or through telecommunication devices, individually or in small groups. If a child is physically able to complete work, but does not do so after a three-week period, services may be discontinued. To foster a productive learning environment, parents/guardians are requested to provide a work space free from distractions such as the television, the radio, pets, and visitors. Hospital/Homebound Procedures for The School Contact Person School officials review the request and determine if a Hospital/Homebound referral form should be issued. School officials should consider all available options prior to issuing a Hospital/Homebound referral. 12

14 The school contact person will provide the parent with Hospital/Homebound guidelines including the referral request. The school contact person will provide answers to any questions that parents may have about the program. The Hospital/Homebound contact person is responsible for obtaining required forms from the parent and physician. The Hospital/Homebound contact person is responsible for sending the completed referral to the central office for approval by the Special Education Director. Once approved, the Hospital/Homebound contact person is responsible for securing a teacher to perform the homebound services in a timely manner. The contact person is responsible for informing the teacher performing the homebound services of the procedures and guidelines. The contact person will collect the time sheet and forward the time sheet to the central office for payment. The contact person will coordinate with the attendance office to ensure that services and attendance figures are accurate. 13

15 Calhoun City Schools Hospital/Homebound Referral Revised 10/2010 HOSPITAL/HOMEBOUND SERVICES Calhoun City Schools, under State Board Rule , is authorized to provide instructional services to eligible students who have a medically diagnosed physical or mental condition that confines the student to home or hospital and whose activities are restricted for an extended period of time. To be eligible for services, students must meet the following criteria: 1. A licensed physician must certify that the student is expected to be absent from school due to a physical or mental condition, or due to a repeated intermittent chronic condition, for at least 10 school days and will be able to participate and benefit from an instructional program. 2. The student is under medical care for the illness, which may be acute or chronic in nature. 3. The physician must certify that the student can receive instruction without endangering the health of the instructor or other students with whom the instructor may come in contact. Students are not eligible for Hospital/Homebound instructional services if their absence is due to communicable disease, except as specified in state board policy JGCC (Communicable Diseases). 4. Students will not receive services for pregnancy unless there are abnormal restrictions from activities as prescribed by a licensed physician. Services will be provided, however, if such services are specified in the individualized education program (IEP) of a disabled student. 5. Re-documentation of a chronic or recurring condition is not required but may be requested by the program coordinator. PARENT/GUARDIAN AGREEMENT Parents - the success of instruction and progress of the Hospital/Homebound student depend to a great extent upon student cooperation and home planning The parent/hospital staff must provide a quiet setting conducive to learning and free from distractions for the student to work. Consistent times for study should be established between Hospital/Homebound teacher visits. Students receiving Hospital/Homebound services are not to participate in extra curricular activities. An adult must be present during instructional time. The parent/hospital staff must allow Hospital/Homebound personnel and the treating physician to exchange pertinent information regarding the student s medical condition and the impact on educational programming. The parent must work with their Physician to have the Physicians portion of the referral completed The Hospital/Homebound student must participate in the scheduled session with the Hospital/Homebound teacher. Doctor s appointments should be arranged so that they do not conflict with scheduled sessions. When an absence is unavoidable, parents should inform the Hospital/Homebound teacher immediately. Excessive absences and tardiness may cause students to lose Hospital/Homebound services. The parent must sign below indicating that the procedures and policies have been explained to them and they understand the requirements of the Hospital/Homebound program and authorize Calhoun City Schools to receive information from the treating physician regarding the student s medical condition. Student s Name Parent/Guardian Signature Home Phone School: Date Business Phone 14

16 Calhoun City Schools Hospital Homebound Form PHONE: FAX: Revised 10, 2010 NOTE: Hospital/Homebound Instruction is provided for children who have medically diagnosed conditions preventing anticipated school attendance for a minimum period of ten (10) consecutive school days or longer. Students out of school because of a communicable disease, expulsion, suspension, or uncomplicated cases of pregnancy are generally not eligible. SECTION I: PUPIL INFORMATION (To be completed by the school) STUDENT NAME: STUDENT ID#: DOB: PARENT/GUARDIAN: HOME PHONE: BUSINESS PHONE: ADDRESS: SCHOOL: PHONE: GRADE: THE STUDENT IS SERVED BY: 504 IEP REGULAR EDUCATION LAST DAY OF PUPIL S ATTENDANCE: DATE FORM GIVEN TO PARENTS: PRINCIPAL S SIGNATURE: DATE: SECTION II: PARENTAL PERMISSION *IMPORTANT: The parent must sign below indicating that they understand the requirements of the Hospital/Homebound program and authorize Calhoun City Schools to receive information from the treating physician regarding the student s medical condition and the impact on educational programming. PARENT/GUARDIAN SIGNATURE: SECTION III: MEDICAL CERTIFICATION (To be completed by the physician) DIAGNOSIS OF ILLNESS (Print or Type): Is this pupil able to attend school? Is this illness contagious? This pupil is able to receive instruction with the following limitations: Approximate number of day s student will require H/H services: *IMPORTANT: Since the H/H Program is approximately three (3) hours per week, it cannot be a substitute for the student s regular school program. The Special Education Department may need to call your office for additional information on some students when determining compliance with Georgia State Guidelines. By signing below, I certify that HHB services are requested, medically necessary and appropriate for this student. DATE: PHYSICIAN S NAME (Please Print): PHYSICIAN S SIGNATURE: GA LICENSE # PHONE ADDRESS: ATTENTION PHYSICIAN: Please forward form to: Bob Orfield Special Education Director 380 Barrett Road Calhoun, GA Fax By signing below, with approval I certify that this student meets school eligibility requirements for HHB services. SECTION IV: DIRECTOR S EVALUATION: APPROVED: NOT APPROVED: DIRECTOR S SIGNATURE: DATE: 15

17 Teacher Correspondence Log Teacher Type Date/Time Parent/Student Phone/ praise discipline grades request meeting other: Notes: Type Date/Time Parent/Student Phone/ praise discipline grades request meeting other: Notes: Type Date/Time Parent/Student Phone/ praise discipline grades request meeting other: Notes: Type Date/Time Parent/Student Phone/ praise discipline grades request meeting other: Notes: 16

18 Calhoun City Schools Hospital/Homebound Monthly Report Instructions In order to be paid for hospital/homebound, this form must be completed, signed by the administrator, and included in the monthly payroll report which is sent to the Central Office. Teachers will be paid an hourly rate based on the Georgia Teacher Salary Schedule. A copy of this form must also be sent to the special education office to be used for documentation of Standard I.21. Month, H/H Teacher Grade Student School Beginning Date Ending Date Date Hour Signature of Adult Present Relationship Oath Total Hours for Reimbursement I do solemnly swear, under penalty by law, that the above statements are true in the discharge of my official duties for the Calhoun City Schools. I further solemnly swear that another adult was always present each time listed above and remained the entire time. Employee Signature Date Approved by Principal 17

19 ASSIGNMENT SHEET DATE ASSIGNMENT DATE DUE COMPLETE LATE GRADE 18

20 Contact Information Form Student Name Phone Address Student lives with ( ) Both Parents ( ) Mother ( ) Father ( ) Other Please Specify if other Mother s Name Place of Employment Work Phone Other Father s Name Place of Employment Work Phone Other Guardian Place of Employment Work Phone Other Emergency Contact Relationship Phone Other helpful contact information 19

21 Calhoun City Schools WEEKLY PROGRESS REPORT This report is available to provide information to parents and classroom teachers of the hospital/homebound students weekly progress. Close communication is essential in order to provide a seamless transition back into the regular classes. Date: Student Name: Teacher Name: Course: Teacher Please describe this student s: Attitude/Behavior: Effort: Assignments: Tests: Grade to Date: Comments: Parents: If you have any questions concerning this information, please feel free to contact the homebound service teach 20

22 Calhoun City Schools - Intake/Referral Form General Information: Todays Date: Type of Referral: (circle one) Hospital/Homebound Intermittent Homebound Is this person currently in the hospital? YES NO Student Information: Student Name: DOB: (mm/dd/yy) Address: Phone: Reason for Referral & Miscellaneous Information: (Please be brief, you can explain in full when you are contacted by the school ) Estimated time student will be absent from school After this is completed please return the form to the school for processing. Someone will call you to complete the referral process and confirm information. 21

23 Student Re-entry from Hospital/Homebound Services Students that re-enter from Hospital/Homebound services may need a period of adjustment when returning to the regular class. Please be aware of the need of additional services such as counseling, effects from injury, or medication. The regular classroom teacher in conjunction with the homebound teacher and parents may need to coordinate a re-entry plan for the student. Student s Name Date Grade Homeroom Teacher School Please check any areas in which the homebound student experienced difficulty. Reading Reading Comprehension Spelling Speaking Activities Listening Activities Informal Writing Formal Writing Math Computation Word Problems Math Concepts Social Studies Science Lang. Arts Using the key below, rate the student s progress. Key: 4 - Outstanding progress 3 - Good progress 2 - Average progress 1- Needs improvement NA - Not applicable Listens with understanding Reads with understanding Understands basic concepts Expresses ideas in writing Follows directions Works independently Attendance Participates in discussion Additional comments: 22

24 Hospital/Homebound Parent Survey Please take a moment while you wait to give us some information to help us better serve our stakeholders Please circle the number that best the statements below answers Don't know Strongly disagree Disagree Agree Strongly Agree 1. Teachers at the school motivate my child to want to learn. 2. This school is meeting the academic needs of my child. 3. My child's school reports are informative and they indicate achievements levels. 4. The procedures for homebound services were explained to me when requested 5. The school contact person was very prompt in beginning the homebound paperwork 6. My child's homebound teacher is committed and enthusiastic in his/her approach to teaching. 7. The approval process was handled quickly. 8. My child can explain what he/she is learning each day. 9. There was good communication with the homebound teacher, classroom teacher and myself. 10. My child was able to stay current in his/her assignments in homebound program What suggestions do you have for improving the Hospital/Homebound program? : The standard of work expected: How the students are taught: Improving parental involvement: Other comments?... 23

25 Thank you very much for your time and thoughts The information you have provided will help the school enhance the quality of education for your child(ren). Internet Resources for Students Brain Pop Calhoun City Schools Calhoun Gordon County Library Catalog Connect With Kids Gaggle.net Georgia CRCT Online Georgia Online Assessment Georgia Performance Standards Learning.com Nettrekker PLATO Study Island Testgate Student Sign In World Book Online GA College Ga DOE Test Prep Information... GA Virtual School (GaDOE)... Natl K-12 For Language Res Ctr... SAT Registration... SAT Online Course... SAT Words (Monthly)... Subject Review Site... Math Playground Math-A-Rama Matho Owl & Mouse Educational Resources Spelling City 24