BURKE COUNTY PUBLIC SCHOOLS
DESCRIPTOR TERM: DESCRIPTOR CODE: ISSUED DATE:
HOSPITAL/HOMEBOUND LATEST DATE REVISED: CROSS
PROGRAM 03/08/2012 REFERENCE:
REGULAR EDUCATION HOSPITAL/HOMEBOUND PROGRAM
DEFINITION: Any student who is expected to be confined for four (4) weeks or longer to
hospital or home treatment due to a medical issue or for a period of recuperation is
eligible for this program. The primary purpose is to maintain access to a free and
appropriate public education and to gain access to the general curriculum in order to
support the student’s growth development and academic performance.
The primary objective of the Hospital/Homebound Program is to provide
tutorial/instructional services so that the student can return to school with the knowledge
and skills sufficient to maintain his/her previous level of academic performance. All
students to the extent that they are unable to attend school may receive one-on-one
services for a Hospital/Homebound teacher at local hospitals or in their homes.
HOMEBOUND PROGRAM PRIORITIES
1. Accident Victims
3. Extended Illness
5. Other as determined by medical documentation or IEP
Once a student has been identified by the principal or designee and the physician’s
documentation has been received, Hospital/Homebound Instruction may begin
immediately. The following steps should be used in registering students for the program.
1. Request submitted to school by parents or guardian.
2. Medical documentation sent to principal’s office.
3. Parental Consent Form sent to principal’s office.
4. Completed Packet sent to the Director for Exceptional Children.
5. Director for Exceptional Children approves or denies request.
6. Director for Exceptional Children works with school contact to identify needs
7. Homebound Instructor contacted.
8. Necessary paperwork given to Homebound Instructor to proceed with services.
9. Hospital/Homebound instruction begins as follows:
a. Homebound Instructor should request the school to indicate specific
objectives, competencies, and performance indicators to be used during
the period of confinement.
b. Hospital/Homebound instructors should have the same access to texts,
resources and instructional materials as any other teacher employed by
the same LEA.
c. When objectives, competencies, and performance indicators provided by
the sending/home school are used by certificated personnel, grades
given and assignments completed should be accepted as appropriate
indicators of student achievement.
d. The LEA administrators should assure that Hospital/Homebound
students receive the maximum instructional services time appropriate
given the student’s condition. The goal is receive appropriate levels of
e. All students served as Hospital/Homebound are to be counted present
at school. Therefore, no absence code should be used. Until
Hospital/Homebound services are actually delivered, the student should
be coded as lawfully absent from school.
10. Physician’s release form obtained by school.
11. Hospital/Homebound instruction complete
o Serves students weekly determined by teacher.
o Student must have medical reason for homebound services.
o Must have doctor and parent recommendation.
o Provides services so student can return to school with reasonable knowledge
and skill to continue.
o Limited duration but minimum of four (4) weeks out of school.
o Keeps students on class roster.
o Develops plans, instructions, and reasonable amount of work.
o Grades student work, answers questions, and assists students.
o Has assignments on day, time, and place designated by principal.
o Works up to three (3) hours per week with student with no additional time for
travel or preparation.
o Explains work, answers questions, and assists student.
o Does not prepare assignments or issue grades.
o Has access to instructional texts, manuals, and guides.
o Paid at their hourly certification rate.
BECAUSE STUDENTS ON HOMEBOUND STUDY ARE NOT IN THE CLASSROOM, IT IS NOT
LOGICAL TO ASSUME THAT THEY CAN HANDLE THE EXACT ASSIGNMENTS THAT ARE
GIVEN IN CLASS. THEREFORE, CARE SHOULD BE TAKEN WHEN MAKING ASSIGNMENTS
FOR HOMEBOUND STUDENTS.
Parent Signature _______________________________________________
Student Signature ______________________________________________
School Official Signature (s) _______________________________________
Checklist for Hospital/Homebound Services
Student’s Name: Assigned School:
Grade Level: Contact Phone Number:
___________________ Medical Documentation / IEP
___________________ NC Wise Demographic Printout
___________________ Physician Referral Form Completed
___________________ Central Office Approval/Denial
___________________ Instruction Begins
___________________ Physician’s Release Form Obtained
___________________ Homebound Instruction Completed
___________________ Student Returns To School
SCHOOL REQUEST FORM
________________________________________ School is requesting permission to
enroll (student name) ____________________________________________ in the
Hospital/Homebound Program. Attached is the NC Wise student demographic sheet and
required Physician Referral Form.
The primary reason and time of confinement:
Parent Signature / Date Principal’s Signature / Date
CENTRAL OFFICE USE ONLY
___________ This request has been approved.
___________ This request has been denied.
Signature / Date
Burke County Public Schools
Hospital/Homebound Physician Referral Form
Note: Homebound placement is a temporary placement for children with chronic, severe, and/or
terminal illness. It is not designed to take the place of the school experience. Refer to page
two for information regarding students identified as medically fragile. Continuing need for
homebound services must be reviewed on a monthly basis. Each child should have a plan for
transitioning back to school.
Section A to be completed by the parent.
Child’s Name DOB Grade
Parent’s Name Phone (H) (W) (C)
To be completed by the parent: I give permission for , (Name) County
Schools, to discuss my child’s presenting medical needs/condition, with my child’s physician and/or my child’s psychiatrist,
psychologist, or other therapist, as his/her needs/condition relate to my request for homebound services.
Parent’s Signature Date
The child’s physician must complete and sign Section B if the child cannot attend school due to medical reasons.
The child’s psychiatrist, psychologist, or other type of therapist must complete and sign Sections B and C if the child cannot attend
school due to mental health reasons.
Section B To be completed by the child’s physician; and/or psychiatrist, psychologist, or other type of therapist.
Physician’s Name Name of Practice
Please Print Name Please Print Name of Practice
Office Telephone Office Fax
Name of Practice
or other Therapist’s Name Please Print Name Please Print Name of Practice
Office Telephone Office Fax
1. Specific medical diagnosis that prevents the student from attending school.
2. Explain why this prevents the student from attending school? If more space is
needed, please use the back of this page.
3. Could this student attend school if an alternative schedule was established, e.g. modified or alternate day schedule? Yes No
4. If yes, what are your specific recommendations?
5. Please estimate the amount of time the student will be confined to the hospital
and/or home for the stated medical reasons.
6. If pregnant, what is the estimated delivery date?
7. How long will the student need to stay home after delivery?
8. Is the student free from communicable diseases? Yes No
9. When will the student be physically able to begin services. (Date)
Section C : To be completed by the child’s psychiatrist, psychologist, or other type of therapist.
10. When did you last see this student?
11.How often will you be seeing him/her?
12.Do you have a treatment plan in place and a plan for transitioning him/her back to school? Yes No
Physician’s Signature (Date)
Psychiatrist, Psychologist, or other
Therapist’s Signature (Date)