Download Homebound for Pregnancy Form

Please read completely before taking these forms to your child’s
physician.
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All forms must be completely filled out before returning them to
the special education office.
Be sure to sign the information release form so that we can get
information from the doctor.
You must meet with Ms. Ivey so that she can assign a teacher to
teach your child.
If your child’s homebound services need to be extended beyond
the original date, you must get additional forms from the doctor by
the date the homebound expires.
Parents, your child is NOT on homebound until we receive
the forms from the doctor and you have a meeting with Ms.
Ivey.
Physician Certification
TCA Section 41-10-1101-1104 provides for homebound instruction for pregnant
students. Under this law, each pregnant student is entitled to three (3) hours of
homebound instruction per week through a six-week period of maternity leave. If the
student’s physician certifies in writing that the student’s medical condition prevents
the student from returning to regular classes, they can continue to receive three hours
of homebound instruction per week.
Please complete the following information:
Student______________________________________________________________
School_____________________________________ Grade____________________
MEDICAL CERTIFICATION
Expected date of delivery_______________________________________________
HOMEBOUND SERVICES TO BE RENDERED: (please check)
____Prior to delivery—List medical complications (update every 4 weeks)
____6 week period beginning with delivery
____Beyond 6 week maternity period—List medical conditions (update every 4
weeks)
___________________________________________________________
___________________________________________________________
___________________________________________________________
Symptoms common to pregnancy include back pain, fatigue, nausea and vomiting.
These are not considered complications unless hospitalization or total bed rest is
prescribed. For the purpose of pregnancy related homebound, complications should
be documented with a diagnosis code. Examples of pregnancy complications include,
but are not limited to gestational diabetes, eclampsia, placenta tear, any complications
requiring hospitalization, etc.
Physician:_________________________________________________________
_________________________________________________________
_________________________________________________________
Phone_____________________Fax____________________________
Physician signature_________________________________________________
MUST BE SIGNED BY A PHYSICAN