Brownsville Independent School District

Student: / ID #: / DOB: / Gr.: / Campus: _

Any student who is served through the General Education Homebound (GEH) program must meet the following three criteria:

1.  Student is expected to be confined at home or hospital bedside for a minimum of four consecutive or cumulative weeks;

2.  Student is homebound for medical reasons only; and

3.  Medical condition must be documented by a physician licensed to practice in the United States. (Completion of form MED-4 is required.)

Name of Physician:

Doctor’s Office/Address:

Medical Condition/Diagnosis:

Approximate Length of Confinement:

Based on the physician’s note or letter, together with the GEH Committee’s review of current evaluation data (including parent input, teacher/administrator input, grade reports, sample of student work, standardized tests and/or other tests as determined appropriate, etc.) the GEH Committee has determined that the student is:

Eligible for Homebound Instruction: Yes No

Type of Homebound Instruction: Home Hospital Bedside

If “Yes”, please check (ü) the amount of time to be provided to the student per week:

ü / Amount of Time to Be Provided / Equivalent / Subject Area(s)
One Hour per Week / One day present
Two Hours per Week / Two days present
Three Hours per Week / Three days present
Four or More Hours per Week / Four days present
Five days present

8-2014

5-9

General Education Homebound services will be provided to the student in the following areas:

Yes / No / Access to textbooks, assignments, projects, and tests for self-study in the following subject areas:
Yes / No / Access to classroom teachers by phone in the following subject areas:
Yes / No / Extended time for the completion of projects in the following subject areas:
Yes / No / Access to educational software, distance learning, correspondence courses, or other on-line instruction. If “Yes”, detail services to be made available:
Yes / No / Other:
Yes
N/A / No / Formal transition from General Education Homebound to the classroom. (If the GEH Committee believes that a formal transition period is required for the student’s return to school, please detail the transition calendar and steps for implementation.)

Certified General Education Teacher(s):

Note: The teacher providing GEH instruction shall maintain a log of contact hours and other appropriate documentation of the provision of the required services.

Homebound Services “Start” Date:

Homebound Services “Stop” Date:

General Education Homebound/§504 Committee Members: (Principal, Teacher, Parent/Guardian required at a minimum)

Principal
Teacher
Teacher / ______
Signature
______
Signature
______
Signature / Parent/Guardian
Teacher
Other / ______
Signature
______
Signature
______
Signature

*For students found eligible under Section 504, F-9 must be completed indicating instructional accommodations to be implemented by the GEH teacher providing services to the student.

8-2014

5-10