6:150-E 1 – Physician’s Statement for Temporary Home or Hospital Education

On District Letterhead

Student Informatioan:

Student Name:  ________________________________    DOB:  ______________

Address:  ___________________________________________________________

Physician’s Information:

Physician’s Name:  _____________________________  Phone:  ___________

Type of Physician:  _______________________________________________

Address:  _______________________________________________________

The student will require educational services ______ at home and/or _______ at a hospital:

_______ for more than 10 days

_______ for recurrent periods of less than 10 days that will accumulate to more than 14 days in the school year.

The school district should consider the following medical information when planning instructional services:

___________________________________________________________________________

___________________________________________________________________________

The student’s health during this period(s) ________ will affect _______  will not affect _______ the provision of full educational services.  If services will be affected, please explain why and how services will be impacted.

___________________________________________________________________________

___________________________________________________________________________

The student is expected to return to school on ___________. (MM/DD/YY)

Physician’s Signature:  _____________________________________________

Date:  ____________________________

Date Adopted:  January 11, 2012