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Please read completely before taking these forms to your child’s physician. 1. 2. 3. 4. 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