697 Homebound Instruction Forms

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					                                                                                                   Adopted 4-28-2010




              HIAWATHA VALLEY EDUCATION DISTRICT POLICY 697
                                 HOMEBOUND INSTRUCTION FORM

                                     Building _______________________

               ALC Coordinator ________________                Homebound Teacher _____________

              Classroom Teacher _______________                Principal _______________________

                                       HOMEBOUND PLAN / HS
Name of Child: ____________________________             Parent’s Name: ____________________________
Address: _________________________________              Phone: ___________________________________
Name of Doctor: ___________________________             School: ___________________________________
Homebound Teacher: _______________________              Grade: ___________________________________
Nature of Ailment: _________________________            Anticipated Duration: _______________________
Date of Referral: ___________________________           Date Instruction Starts: ______________________

                                   MODIFICATIONS TO SCHEDULE

Student’s Classes                   Modifications to Schedule
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

                                               Classroom                     ALC                Homebound
                                               Instruction                Instruction            Instruction
Grading done by:                           ________________           ________________       ________________
Curriculum materials
Provided by or approved by:                ________________           ________________       ________________
Classroom teacher signature:               ________________           ________________       ________________

                                               Classroom                     ALC                Homebound
                                               Instruction                Instruction            Instruction
Grading done by:                           ________________           ________________       ________________
Curriculum materials
Provided by or approved by:                ________________           ________________       ________________
Classroom teacher signature:               ________________           ________________       ________________

                                               Classroom                     ALC                Homebound
                                               Instruction                Instruction            Instruction
Grading done by:                           ________________           ________________       ________________
Curriculum materials
Provided by or approved by:                ________________           ________________       ________________
Classroom teacher signature:               ________________           ________________       ________________

Signatures:                              Building Principal:              _______________________________
                                         Parent:                         ______________________________
                                         Homebound Teacher:              ______________________________
                                                 697-1
                                                                                                     Adopted 4-28-2010




              HIAWATHA VALLEY EDUCATION DISTRICT POLICY 697
                                   HOMEBOUND INSTRUCTION FORM
                                       Building _______________________

               ALC Coordinator ________________                  Homebound Teacher _____________

               Classroom Teacher _______________                 Principal _______________________

                                   HOMEBOUND PLAN / WMS/ELEM
Name of Child: ____________________________               Parent’s Name: ____________________________
Address: _________________________________                Phone: ___________________________________
Name of Doctor: ___________________________               School: ___________________________________
Homebound Teacher: _______________________                Grade: ___________________________________
Nature of Ailment: _________________________              Anticipated Duration: _______________________
Date of Referral: ___________________________             Date Instruction Starts: ______________________

                                      MODIFICATIONS TO SCHEDULE

Student’s Classes                   Modifications to Schedule
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

                                                  Classroom                    ALC                Homebound
                                                  Instruction               Instruction            Instruction
Grading done by:                              ________________          ________________       ________________
Curriculum materials
Provided by or approved by:                   ________________          ________________       ________________
Classroom teacher signature:                  ________________          ________________       ________________

Signatures:                                Building Principal:              _______________________________
                                           Parent:                         ______________________________
                                           Homebound Teacher:              ______________________________

Homebound Teacher Responsibilities to Classroom Teacher
     *Contact classroom teacher for materials and assignments.
             *Elementary – weekly
             *Secondary – entry and exit unless requested
     *Complete a brief narrative which reflects the subject and units covered, areas of concern, and assigned
     grades for the period of instruction, and in collaboration with the classroom teacher, develop final grades.

 Classroom Teacher Responsibilities:
       *Provide or approve content, text, required assignments and manuals.
       *Collaborate with the homebound teacher regarding grading.
       *Submit grades to building principal.

                                                      697-2
                                                                         Adopted 4-28-2010



                              HOMEBOUND REPORT



NAME ______________________________________ START DATE __________________


CLASS ______________________________________ END DATE ____________________


TEACHER ________________________ HOMEBOUND TEACHER __________________


REPORT:    ATTENDANCE, WORK COMPLETED, ETC.




GRADE RECOMMENDED ____________________________




                                       697-3

				
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