Pregnancy Related Services (PRS) / Homebound Teacher Forms

Student Alternatives Program, Inc.

Pregnancy Related Services (PRS) / Homebound Teacher Forms

______/ ______

Student ID # Grade Age Campus

Please use this checklist to ensure that each PRS packet is complete and in the following order (Initials required when completed by responsible person):

PRS DIAGRAM AND DIAGRAM NARRATIVE

TEACHER FORMS:

• Excuses (from doctors), if applicable

• Child Protective Services (CPS) (for nurses), if applicable

I certify that this record is complete. ______

Date

______

Campus Authorized Official Signature

______ ______

Academy Director SignatureDate

Pregnancy Related Services

PEIMS COORDINATOR

 Ensure accurate coding

(Form #1).

CSHD DIRECTOR

 Coordinate CEHI.

 Communicate with Sp. Ed.

Coordinator, prn.

CEHI Certified Teacher

 Facilitate CEHI process.

 Complete CEHI notification when CEHI

**Special Note:For Charter Districts with more than one campus and a functioning District Office, reference to campus PEIMS Coordinator will also stipulate submission to DO PEIMS Coordinator.

Pregnancy Related Services (PRS)

Diagram Narrative

1. Verify the pregnancy. Complete and distribute PRS form # 1 to campus PEIMS, coordinators, attendance and all Team Members. Campus Designee requests academic support, if student is at risk.
2. Begin Enrollment Application (Form # 2). This may be initiated by the nurse or social worker or Campus Designee.
3. Complete Student Service Plan. There must be an entry by all providers as indicated.
4. Implement Compensatory Education Home Instruction (CEHI).

a) Two weeks prior to delivery the campus designee provides the student with the eligibility for CEHI Form for doctor’s recommendations. Have student return completed form to the campus designee. If student has pregnancy complication the doctor may order prenatal CEHI (Form # 4).

b) If complications arise, the campus designee will notify the CEHI Coordinator/Academy Director, who in turn, will notify CEHI teacher.

c) CEHI teacher communicates student’s entry into CEHI via PRS Form # 5.

d) When student returns to school full time, the CEHI teacher will complete PRS forms (Form # 7) to exit student from PRS services, and will be coded as PEP or NA, if student has delivered. If still pregnant, student is still PRS.

1. If the student has a miscarriage or withdraws from school before CEHI services can be initiated, the campus designee will complete PRS Exit Form # 7, notifying all team members that student has “exited” PRS.

Pregnancy Related Services (PRS)

Confirmation of Pregnancy

Student: ______Campus: ______

DOB: ______ID#: ______

Physician Signature: ______Date: ______

(NO SIGNATURE STAMPS ACCEPTED)

Telephone: ______

Contact Person: ______Phone: ______

Nurse

Fax No: ______

PLEASE RETURN FORM TO SCHOOL NURSE or CAMPUS DESIGNEE

Pregnancy Related Services (PRS)

STUDENT DATA RECORD

DISTRICT: ______CAMPUS: ______

Student: ______ID #: DOB: ______

Grade: ______SS #: ______

********************************************************************************************************

REFERENCE: Texas Education Agency Student Attendance Accounting Handbook, Section IX. Use of this form will satisfy TEA Audit requirements for PRS.

A COPY OF THIS FORM SHOULD BE RETAINED IN STUDENT PRS FILE FOLDER FOR A PERIOD

OF NOT LESS THAN FIVE (5) YEARS.

********************************************************************************************************

PRS ENTRY DATA

Date of Pregnancy Verification: ______

Verifying Official / Title: ______

Pregnancy Related Service Entry Date: ______

********************************************************************************************************

COMPRENSATORY EDUCATION HOME INSTRUCTION RECORD

PRENATAL POSTPARTUM

CEHI ENTRY / EXIT DATES: ______

CEHI ENTRY / EXIT DATES: ______

SPECIAL EDUCATION HOMEBOUND RECORD (IF USED)

HOMEBOUND ENTRY / EXIT DATES: _____/ __

********************************************************************************************************

PRS PROGRAM EXIT DATA

Date of Birth of Baby / Pregnancy End Date: ______

Date of Student Returned to Full Time Classroom: ______

Official PRS Program Exit Date: ______

Pregnancy Related Services

______

Campus

Regular Ed: ______

Special Ed: ______

______

Student Grade Age ID#

Verification date: ______by: ______

Staff name

Estimated delivery date: ______

PEIMS PRS coding entry on: ______by: ______

Date Staff name

______

PEIMS exit from PRS: ______by: ______

Date Staff Name

Reason:

Withdrawn Medical Reasons Graduated End of School Year

Copy to: ALL THAT APPLY

Attendance

Counselor

Nurse

CEHI Teacher

PEIMS District/Campus Coordinator

Academy Director

FORM #1

Pregnancy/Parenting Related Services

Enrollment Application

DATE: ______STUDENT STATUS: Preg. Parent:

______

Last Name First MI ID# SS#

Sex: M F Age: DOB: Grade: Marital Status: M Sg S D

______

Maiden Name Address City Zip code

______

Who do you live with? Relationship Telephone

______

Parent(s)/Guardian(s) ` Address Telephone

______

Emergency Contact Address Telephone

Are you currently pregnant? Y N. If yes, due date? Have you seen a doctor?YN

Name of Doctor? ______Name of Health Care Facility ______

Other children: Y N. If yes, please complete following information.

Name(s) of Child/children __Sex: M/F __Date of Birth _____ SS#

______

Do you have child care for this school year? Y N

______

If yes, name of Care Giver: Relationship Telephone

Do you need assistance with child care while you are attending school? Y N. If yes, explain:

______

______

SOCIAL SERIVCE INFORMATION: Check any service you currently receive.

AFDC MEDICAID FOOD STAMPS WIC PUBLIC HOUSING

CHILD CARE MANAGEMENT SERVICES. OTHER, SPECIFY ______

______

Name and title of person assisting in enrollment: ______

FORM #2

Student Status

Preg.(EDC): _

Parent: ____

Pregnancy/Parenting Services

Student Service Plan

Student ______ID#______Grade_

Migrant Title 1 Sp. Ed. 504 Vocational

Date and initial all entries; provide signatures at the bottom of the form.

Health Plan:

______

______

Academic Plan:

______

______

Social Services Plan: ______

______

Counseling Plan: ______

______

Other Services: ______

______

Day Care: ______

Transportation: ______

Employment: ______

Provider

Signatures: ______

______

FORM #3

Pregnancy Related Services (PRS)

Eligibility for Compensatory Education Home Instruction (CEHI)

TO HEALTH CARE PROVIDER: In order for the student to receive home instruction, a pregnancy related medical reason must be indicated.

Student: ______DOB: ___ Age: ___

ID #: ______Grade: ______School: ______

Address: ______Phone (H):

Parent/Guardian: ______Phone (B):

1. Expected date of delivery: ______
2. Date of last exam: ______
3. Are there any complications at this time that would require the student to stop

attending school and remain at home? Please specify (Medical Reason):

______

1. Approximate length of confinement after delivery: ______

PHYSICIAN’S PRINTED OR TYPED NAME: ______

(Must be U.S. doctor practicing in Texas)

Physician’s Signature: ______Date: ______

(NO STAMPED SIGNATURES ALLOWED)

Address: ______Phone: ______

Fax: ______

For questions, please call ______at ( ) ______

Campus Nurse Phone

cc: ALL THAT APPLY

Nurse OR Campus Designee

CEHI Teacher

Academy Director

PRS FORM #4

Pregnancy Related Services – Supplementary Notes

______

Campus

_________

Student Grade Age ID#

Page _____ of _____

CONSENTIMIENTO PARA REVELACIÓN DE INFORMACIÓN CONFIDENCIAL

Yo, ______autorizo a

(Nombre del alumno o del padre)

la enfermera escolar para que dé a conocer la siguiente información:______

(Nombre o designación general del programa que hace la revelación, Ej.: proveedor de servicios de salud)

• Prueba de embarazo ______
• Confirmación de posible fecha de parto______
• Información relacionada con el embarazo______

______

El propósito de la revelación autorizada por medio de esta carta es proporcionar atención prenatal y consejo mientras la alumna asiste a clases en la escuela.

______

(Que el propósito de la revelación sea lo más específico posible.)

Entiendo que mis expedientes están protegidos bajo reglamentos federales en el

Acta de Derechos de Educación Familiar y el Acta de Privacidad, y/o los reglamentos

federales que gobiernan los Expedientes de Privacidad de los pacientes que abusan de

las drogas y el alcohol, 42 CFR Parte 2, y no pueden ser divulgados sin mi

consentimiento por escrito, a menos que se exprese lo contrario en los reglamentos

aplicables. También sé que puedo revocar este consentimiento en cualquier momento

excepto si se ha tomado acción en confianza, y en cualquier caso, este consentimiento

caduca automáticamente de la siguiente manera:

______

(Especificaciones de la fecha, evento o condición sobre los cuales caduca este consentimiento.)

______

Fecha Firma del alumno

______

Firma del padre, guardián, o representante autorizado

se requiera

06/2011

CONSENT FOR THE RELEASE OF CONFIDENTIAL INFORMATION

I, ______authorize

(name of student or parent)

______

(name or general designation of program making disclosure i.e. Health Care Provider)

to disclose to the school nurse(s) the following information:

• Proof of pregnancy ______
• EDC ______
• Pregnancy related information ______

The purpose of the disclosure authorized herein is to provide prenatal care and counseling while at school. ______

I understand that my records are protected under the federal regulations in the Family Education Rights and Privacy Act, and/or the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the applicable regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:

______

(specifications of the date, event, or condition upon which this consent expires)

______

Date Signature of student

______

Signature of parent, guardian, or authorized

representative when required

TRANSFER OF PRS FOLDER

DATE: ______

TO:Nurse or Campus Designee: _____ Campus: ______

FROM:Nurse or Campus Designee: _____ Campus: ______

On the above referenced date, the PRS folder for:

Student: ______ID #: ______DOB: ______

was sent to you via interschool mail.

Please sign below acknowledging receipt of the folder and send a copy of

this acknowledgement back to me.

______

Receiving School Nurse or Campus DesigneeDate Received

Student Alternatives Program, Inc.

Campus Name:______

Compensatory Education Home Instruction (CEHI)

Instruction Log

Homebound Teacher’s Name: ______

Student Name: ______Grade: ____

ID #: ______D.O.B: ______S.S. #: ______

Address: ______Phone #: ______

Parent/Guardian’s Name: ______

A general Education student served at home earns eligible days present based on the number of hours the student is served at home by a homebound teacher each week. Eligible Days Present: 1hr=1day 2hrs=2days 3hrs=3days 4hrs(+)=4days in a 4-day week/5days in a 5-day week.

Eligible days present are determined each week. For GEH purposes, a week starts Sunday and ends Saturday. GEH service hours may not be accumulated and carried forward from one week to the next, nor may services hours be applied to a previous week. (SAAH 10-11)

______

(Printed Name of Homebound Teacher)(Signature)

Student Alternatives Program, Inc.

07/2011