HOMEBOUND PACKET
Regular Education
&
Special Education
CONTENTS OF HOMEBOUND PACKET
PROGRAM DEFINITION AND INITIAL RESPONSIBILITIES.........................................................................2
HOMEBOUND SERVICES FLOW CHART ...........................................................................................................3
PROCEDURES FOR HOMEBOUND SERVICES..................................................................................................4
CAMPUS NURSE’S HOMEBOUND PACKET .......................................................................................................5
RESPONSIBILITIES OF CAMPUS NURSE .......................................................................................................6
NURSE’S HOMEBOUND SERVICE SUMMARY .............................................................................................7
NURSE’S ANECDOTAL RECORD .....................................................................................................................8
PARENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS ...................................................9
REQUEST FOR HOMEBOUND SERVICES .................................................................................................... 10
HOMEBOUND PHYSICIAN’S FORMS ................................................................................................................ 11
PHYSICIAN'S MEDICAL REPORT .................................................................................................................. 12
PHYSICIAN'S RELEASE OF HOMEBOUND SERVICES ............................................................................. 13
PHYSICIAN’S CONTINUATION OF HOMEBOUND SERVICES .............................................................. 14
HOMEBOUND COMMITTEE ............................................................................................................................... 15
504 HOMEBOUND PLAN ................................................................................................................................... 16
HOMEBOUND ATTENDANCE NOTIFICATION .......................................................................................... 18
HOMEBOUND TEACHERS PACKET .................................................................................................................. 19
RESPONSIBILITIES OF TEACHERS PROVIDING HOMEBOUND SERVICES ..................................... 20
RESPONSIBILITIES OF FAMILIES OF STUDENTS RECEIVING HOMEBOUND SERVICES............ 21
HOME INSTRUCTION ASSIGNMENT RECORD.......................................................................................... 22
INSTRUCTIONAL & RELATED SERVICES ATTENDANCE RECORD 2012-2013 SCHOOL YEAR ... 23
HOMEBOUND ATTENDANCE LOG 2012-2013 ............................................................................................. 24
HUMBLE I.S.D.
HOMEBOUND EDUCATIONAL SERVICES
PROGRAM DEFINITION AND INITIAL RESPONSIBILITIES
The Humble I.S.D. delivery system for providing educational services to students in the home is the
Homebound Program.

Homebound is an instructional arrangement for providing education and related services to
students who are expected to be confined for a minimum of four (4) consecutive weeks as
documented by a licensed physician. Homebound instruction may also be provided to chronically
ill students who are expected to be confined for any period of time totaling at least four (4) weeks
through the school year as documented by a licensed physician. The need for Homebound will be
determined by the ARD/504 Committee based on recommendation from the physician’s report as
well as input from campus personnel and the parents.

Homebound Program Responsibilities:
Nurses and Counselors are responsible for processing requests for Homebound services for
students who have a 504 plan.
Nurses and Diagnosticians are responsible for processing requests for Homebound services for
students who already meet eligibility criteria for Special Education services.
Homebound committees determine the specialized needs of each student and address the needs
through the 504 plan or ARD Committee.
Case manager, campus nurse and/or Counselor will monitor student attendance, academic
progress, and medical condition on a monthly basis and will hold staffings when appropriate.
The Homebound teacher will review parent responsibilities for Homebound at the time of the
ARD/504 and upon the first visit to the student’s home.
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HOMEBOUND SERVICES FLOW CHART
Any student who is served through Homebound Services must meet the following three criteria:

The student is expected to be confined at home or hospital bedside for a minimum of 4 weeks. The weeks need not be consecutive.

The student is confined at home or hospital bedside for medical reasons only.

The student’s medical condition is documented by physician licensed to practice in the United States.
Note to Physician: Homebound Services is considered the most restrictive educational setting. Reasonable accommodations for the physical,
emotional, and educational needs of the student often can be made within the school setting. There is a full-time nurse on every campus.
Parent Requests Homebound Services
Refer to the nurse. The nurse will request a release of information from the parent, gather medical information and assess the
situation to determine if reasonable accommodations are applicable. A staffing will be held to discuss options.
If Homebound is a consideration, the nurse will request completion of Physician’s
Medical Report and complete the Request for Homebound Service.
If Homebound is still a consideration, all documents, Request for Homebound Services, Anecdotal Report, Physician’s
Medical Request and Nurse’s Homebound Summary will be submitted to the Coordinator of Health Services. Following
review of information, the Request for Homebound Services Form will be returned to the campus nurse. A copy will remain
with the Coordinator of Health Services.
The campus nurse will forward information to counselor or diagnostician as appropriate .
No
Homebound still a consideration?
Put accommodations in place as identified
by 504 or staffing committee
Yes
Student in Special Education?
Student is 504?
Diagnostician/LSSP schedules ARD with appropriate
personnel including Homebound teacher.
Counselor schedules 504 with appropriate personnel
including Homebound teacher.
ARD Committee determines appropriate services.
504 Committee determines appropriate services.
The diagnostician/LSSP will complete and disperse
attendance notification form.
The Counselor will complete and disperse attendance
notification form.
Case manager will monitor attendance and academic
progress and the nurse will monitor medical
progress on a monthly basis.
Continuation of Homebound Services needed?
Yes
No
This continuation
procedure will mirror the
initial Homebound process.
Release of Homebound
services and ARD Committee
determine appropriate
accommodations.
rev 02/2013
Counselor will monitor attendance and academic
progress and the nurse will monitor medical
progress on a monthly basis.
Continuation of Homebound Services needed?
Yes
No
This continuation procedure
will mirror the initial
Homebound process.
504 Committee will meet to
dismiss from Homebound
services and determine
appropriate accommodations.
Contact Yvonne Walker at ext 8425 for a Special Education teacher.
Contact Lesa Pritchard at ext 8407 in Student Support Services for 504/Regular Education teacher.
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3
HUMBLE I.S.D.
PROCEDURES FOR HOMEBOUND SERVICES
NOTE: Make parents aware that services cannot start until all information is gathered, an
evaluation is completed, and an ARD/504 committee meets to determine services.
When Homebound education services are requested for a student who is ill, the following action
will be taken:
Step 1: Refer to nurse. The nurse will request a release of information from the parent, gather
medical information and assess the situation to determine if reasonable accommodations
i.e. shortened day/week, are applicable. Following the nurse’s assessment a staffing will
be held to discuss other options at that time.
Step 2: If Homebound is a consideration the nurse will request completion of the Physician’s
Medical Report and complete the Request for Homebound Service.
Step 3: After receiving the Physician’s Medical Report, copies of the Request for
Homebound Service, Anecdotal Record Form, and Nurse’s Summary will be
submitted to the Coordinator of Health Services. Following review of the information,
the Request for Homebound Service will be returned to the campus nurse. A copy
will remain with the Coordinator of Health Services.
Step 4: The campus nurse will forward information to counselor or diagnostician as appropriate.
Step 5: The ARD/504 committee will review the information and determine need for
Homebound services.
Step 6: Following the ARD/504, the diagnostician/LSSP/Counselor will:
A.
B.
Disperse the Homebound Service Attendance Notification as follows:
Diagnostician/LSSP
Audit Folder
Counselor
Attendance Clerk
Student’s teachers
Nurse
Provide the Homebound teacher with a copy of the Physician’s Medical Report.
Step 7: A case manager or counselor and Homebound teacher will monitor attendance and
academic progress monthly. The nurse will monitor the medical condition monthly.
Step 8: Discontinuation of Homebound services will be determined by the ARD/504 committee
with recommendations from the physician, Homebound staff, case manager and nurse.
Step 9: Continuation of Homebound services past the initial recommendation must be reviewed
by the Coordinator of Health Services and determined by the ARD/504 committee. The
Physician’s Continuation of Services form and the staffing recommendations must
accompany the request.
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CAMPUS NURSE’S HOMEBOUND PACKET
a. Campus Nurse Responsibilities
b. Nurse’s Homebound Services Summary – HB Form #1
c. Humble ISD Anecdotal Record Form – HB Form #2
d. Parent Authorization for Release of Medical Records – HB Form #3
e. Request for Homebound Services – HB Form #4
5
HUMBLE I.S.D.
HOMEBOUND PLACEMENT REQUEST
RESPONSIBILITIES OF CAMPUS NURSE
BASIC INFORMATION
1.
2.
3.
4.
5.
6.
Homebound is the most restrictive placement for students.
Student must be in the least restrictive learning environment.
All options for modified school environment must be considered i.e. shortened day/week.
Request for Homebound services must have a medical reason.
Students must be in special education or 504 to receive services.
Monthly contact with the Homebound student must be maintained and documented.
PROCEDURE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Referral may be initiated through the nurse, counselor, diagnostician or LSSP.
The nurse will discuss with the parent the reason for the request. Many times parents and
physicians are not aware of the accommodations that can be made to allow for school attendance.
Obtain a release of medical information.
Discuss needs with counselor/diagnostician/LSSP and arrange a staffing with the necessary
personnel. The staffing may take place prior to the physician’s formal request. It is sometimes
helpful to discuss possibilities before discussion with physician.
Request the physician who is managing the illness to complete the Physician’s Medical Report.
It may be sent and returned electronically. It is helpful to contact the physician to discuss what
accommodations and modifications can be provided prior to the completion of the form.
Have Counselor/LSSP complete the Request of Homebound Services.
After the Physician’s Medical Report is returned, send the following to the Coordinator of Health
Services for approval:
a. Copy of Physician’s Medical Report and Request for Homebound Services – HB Form #5
b. Copy of Release of Information – HB Form #3
c. Request for Homebound Services - HB Form #4
d. Copy of Nurse’s Summary – HB Form #1
e. Copy of Nurse’s Anecdotal Notes – HB Form #2
The Homebound Referral form will be returned to the campus nurse who will distribute copies to
the appropriate personnel.
Special Education/504 procedures, when appropriate, will then be initiated and services will be
determined in the ARD/504 Committee.
Once Homebound services are initiated, communication with the Homebound teacher and family
must be maintained and documented. Regular communication maintains feelings of “belonging
and connectedness.” It facilitates an understanding of the student’s progress and allows for a
smoother effort to return the student to the campus. Communication with the homebound teacher
allows another perspective of the student’s progress and needs. When the student returns to the
campus, there is a better understanding of the student’s academic, emotional and physical needs.
Efforts to return the student to a campus placement should be ongoing.
Continued Homebound placement beyond the anticipated return date must follow the same
procedures as the initial placement.
Physician’s Continuation must be completed.
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HB Form #1
HUMBLE I.S.D.
NURSE’S HOMEBOUND SERVICE SUMMARY
Student’s name
Counselor/Diag/LSSP
Date Referral received
Date Physician Statement received
Phone
Date Authorization for Release of Medical Records received
Date of Staffing
Pertinent information regarding diagnosis:
Reason for homebound request:
What other accommodations are available/appropriate for student?
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Assistance from campus nurse (please specify)
Peer assistance with supplies
Wheelchair assistance to class
Schedule rearrangement
Special seating
Special transportation
Attendance in school for a designated number of days per week (days to be determined)
Attendance in school for shortened school day with teacher support (hours to be determined)
Confinement in the home with reduced instructional services as determined by the ARD Committee
Other (please specify)
Nursing Recommendations
Nurse
Campus
Date
Review Dates:
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HB Form #2
HUMBLE I.S.D.
NURSE’S ANECDOTAL RECORD
Student’s Name
Grade
Counselor/Diagnostician
Phone
Date
rev 02/2013
Information
Plan
8
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HB Form #3
Humble I.S.D.
PARENT AUTHORIZATION
FOR RELEASE OF MEDICAL RECORDS
Instructions: To be completed and signed by parent/guardian or student if 18
years or older. If more than one physician is involved, a release is needed for each.
Purpose of release of records: Communication between school and physician is necessary to facilitate
appropriate educational services for the student and to apprise the physician of the educational options
available to the student.
Student:
School:
D.O.B:
Grade:
Date:
I grant permission for the release of medical records and physician's recommendations related to a
request for educational services. This information will be utilized in accordance with the Family
Education Rights and Privacy Act (FERPA) guidelines to make educational decisions in regard to the
student.
From: (Physician and address)
To:
School Nurse at
and
(campus)
Coordinator of Health Services
Humble ISD
Signature of Parent/Guardian, or
Student, if age 18 or older
rev 02/2013
Date
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HB Form #4
HUMBLE I.S.D.
REQUEST FOR HOMEBOUND SERVICES
Date of Referral
Student's Name
Campus
ID#
Grade Level
Parent's Name
Address
Home Phone #
Mother's Work #
Mother’s Cell #
Father's Work #
Father's Cell #
Anticipated date of return if known
(Must be a minimum of four weeks)
Counselor/Diagnostician/LSSP
Phone #
Is this student having academic problems at this time?
Yes
No
Is this student having attendance problems at this time?
Yes
No
Cumulative absences to date:
Reviewed by Coordinator of Health Services
Date
Comments
Signature, Coordinator of Health Services
Copies are distributed by Coordinator of Health Services as follows:
Diagnostician to place in Audit folder
504 Team
Counselor for 504 folder
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Nurse
Homebound Teacher
10
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HOMEBOUND PHYSICIAN’S FORMS
a. Physician Medical Report – HB Form #5
b. Physician Release of Homebound Services – HB Form #6
c. Physician Continuation of Homebound Services – HB Form # 7
11
HB Form #5
Humble I.S.D.
Campus
Nurse
Phone
Fax
PHYSICIAN'S MEDICAL REPORT
Any student who is served through Homebound Services must meet the following three criteria:
 The student is expected to be confined at home or hospital bedside for a minimum of 4 weeks. The weeks need not
be consecutive.
 The student is confined at home or hospital bedside for medical reasons only.
 The student’s medical condition is documented by physician licensed to practice in the United States.
Note to Physician: Homebound Services is considered the most restrictive educational setting. Reasonable accommodations
for the physical, emotional, and educational needs of the student often can be made within the school setting. There is a fulltime nurse on every campus.
Student:
Date of Examination:
Based upon my examination, this student is experiencing a significant health problem that will necessitate a temporary
change in accommodations or school placement for at least
weeks.
I.
Diagnosis: (Please be specific) Include any complications that cause this case to differ from the norm:
Prognosis:
II.
Options for modified school environment (check one):
A. Assistance from campus nurse (please specify)
B. Peer assistance with supplies
C. Wheelchair assistance to class
D. Schedule rearrangement
E. Special seating
F. Special transportation
G. Attendance in school for a designated number of days per week (days to be determined)
H. Attendance in school for shortened school day with teacher support (hours to be determined)
I. Confinement in the home with reduced instructional services as determined by the ARD/504
Committee
J. Other (please specify)
III.
Anticipated date of return to regular school programming and/or placement:
IV.
Please provide reason/justification for recommendations made.
V.
Please list any precautions that should be observed when working with this student.
Licensed Physician (please print)
Date
Signature: Licensed Physician
Phone Number
NOTE: An additional form must be completed for extension of homebound instruction beyond
anticipated date of student's return to regular school placement.
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HB Form #6
Humble I.S.D.
Campus
Nurse
Phone
Fax
PHYSICIAN'S RELEASE OF HOMEBOUND SERVICES
Instructions: This form is sent to the physician by the campus
nurse. It should be returned directly to the nurse.
To the Physician:
is receiving Homebound educational services due to a
(student's name)
medical condition. Plans for attendance on campus for this student’s educational needs are being
considered. Before the student returns to regular school placement, he/she will need a physician's
statement attesting to his/her physical fitness to enter school or to request a continuation of Homebound
services. Please give us your recommendation by completing this form:
Release of Homebound Services:
a.
Is the return to school of this student recommended?
Yes
No
b. If the answer is Yes, can this student follow the regular school program without any
restrictions?
Yes
No
c.
If No, state any restrictions which are necessary upon his/her return to school:
d.
Date of return:
Licensed Physician (please print)
Date
Signature: Licensed Physician
Date
Copies are distributed by Nurse as follows:
Audit folder/504 folder
Diagnostician/LSSP/Counselor
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HB Form #7
Humble I.S.D.
Campus
Nurse
Phone
Fax
PHYSICIAN’S CONTINUATION
CONTINUATION OF
OF
PHYSICIAN’S
HOMEBOUND SERVICES
SERVICES
HOMEBOUND
Continuation of Homebound services will be determined by the ARD/504 committee. Please return
within five days.
General Education Homebound (GEH)
Any student who is served through Homebound Services must meet the following three criteria:
 The student is expected to be confined at home or hospital bedside for a minimum of 4 weeks. The weeks need not
be consecutive.
 The student is confined at home or hospital bedside for medical reasons only.
 The student’s medical condition is documented by physician licensed to practice in the United States.
Note to Physician: Homebound Services is considered the most restrictive educational setting. Reasonable accommodations
for the physical, emotional, and educational needs of the student often can be made within the school setting. There is a fulltime nurse on every campus.
To the Physician:
is receiving Homebound educational services due to a medical
(student's name)
condition. To request a continuation of Homebound services or accommodations at school, please complete this form:
Based upon my examination, this student is experiencing a significant health problem that will necessitate a temporary
change in school placement for at least
weeks.
I.
Diagnosis: (Please be specific) Include any complications that cause this case to differ from the norm:
Prognosis:
II.
Options for modified school environment (check one):
A. Assistance from campus nurse (please specify)
B. Peer assistance with supplies
C. Wheelchair assistance to class
D. Schedule rearrangement
E. Special seating
F. Special transportation
G. Attendance in school for a designated number of days per week (days to be determined)
H. Attendance in school for shortened school day with teacher support (hours to be determined)
I. Confinement in the home with reduced instructional services as determined by the ARD Committee
for Special Education Services
J. Other (please specify)
III.
Anticipated date of return to regular school placement:
IV.
Please provide reason/justification for recommendations made.
V.
Please list any precautions that should be observed when working with this student.
Signature: Licensed Physician
Date
Licensed Physician (please print)
Date
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HOMEBOUND COMMITTEE
a. 504 Homebound Plan – HB Form #8 (2 PAGES)
b. Homebound Attendance Notification – HB Form #9
15
HB Form #8
Texas General Education Homebound Supplement
Page 1 of 2
Texas General
Homebound
504 Education
HOMEBOUND
PLAN Supplement
[The following form is to be utilized when the §504 Committee is considering placement in General
Education Homebound (GEH). The homebound eligibility decision is made as part of the Section 504
evaluation, utilizing this form, in conjunction with Form 10. The homebound placement decision for a
student who is §504 eligible is made in conjunction with Form 12.]
Date:
Student Name:
Student ID:
School: Grade:
Student Address:
Date of Birth:
Phone:
GEH Committee Membership.
While §504 eligibility is determined by a group of knowledgeable persons, including persons with knowledge of
the child, the meaning of the evaluation data, and the placement options, General Education Homebound eligibility
and placement requires the attendance of three specific people: (1) a Campus Administrator; (2) a Teacher of the
Student; and (3) a Parent or Guardian of the Student. The required groups can and should overlap to satisfy
requirements under both §504 and GEH. Check the boxes to indicate compliance with attendance requirements.
§504 Committee Membership: documented on Form 10
GEH Committee Membership Requirements (provide name of person attending)
Campus Administrator
Teacher of the Student
Parent/Guardian of the Student
Eligibility for General Education Homebound. Pursuant to the 2012-2013 Student Attendance
Accounting Handbook [Handbook], the following must be answered to determine GEH eligibility.
Yes
No
The Committee has received, and attaches to this form, a document from a
physician licensed to practice in the United States, which document:
(1) Indicates that the above-referenced student is expected to be confined at
home or hospital bedside for a minimum of four weeks. The weeks need not
be consecutive.
(2) Indicates that the confinement is for medical reasons only.
Yes
No
Based on the physician’s document, together with the Committee’s review of
current evaluation data (including Parent input, teacher/administrator input, grade
reports, work samples, results of standardized tests, etc., as indicated on the §504
evaluation form (Form 10)), the Committee determines that the Student is eligible
for general education homebound services, and that such services shall be provided
to the Student as indicated below. Pursuant to Handbook instructions, “[T]he
licensed physician’s note/information is not the sole determining factor in the
committee’s decision-making process.”
Results: Where both questions are answered with “Yes,” the student is eligible for General Education
Homebound, and the Committee shall determine the type(s) and amount of instruction to be provided. If
the student is also Section 504 eligible, the committee should also consider whether services on Form 12
are appropriate in addition to the homebound services on page 2 of this form. If either question is
answered “No,” the student is not eligible for GEH services, but may be Section 504 eligible, if so
determined pursuant to Form 10, resulting in the need for a 504 Services Plan using Form 12.
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HB Form #8
Texas General Education Homebound Supplement
Page 2 of 2
General Education Homebound Services.
General Education Instruction will be provided by a certified regular education teacher. Pursuant to
Handbook requirements, over the course of the student’s confinement at home or hospital bedside, “the
student must be provided instruction in all the courses, including elective courses, in which the student is
enrolled.” The student will be provided instruction in the following subject areas (list all subject areas to
be addressed by homebound instruction):
for a total of ____ (#) hours per week of direct one-to-one instruction. [Students served at home through
GEH will earn eligible days in attendance based on the number of hours the student is served at home per
week by a certified regular education teacher. One hour of instruction equals one day in attendance for the
first three hours of GEH instruction each week. When four or more hours of GEH instruction are
provided, the student earns an entire week (five full days) of attendance. [See current Student Attendance
Accounting Handbook for more detail]
Optional services to be considered in addition to direct instruction. Check all those that apply:
Access to textbooks, assignments, projects and tests for self-study in the following subject areas:
Access to classroom teachers by phone in the following subject areas:
Extended time for completion of projects in the following subject areas:
Access to Plato, educational software, distance learning, correspondence courses, or other online instruction. If yes, please detail services to be made available to the student:
Other
Formal transition from General Education Homebound to the classroom. If the Committee
believes that a formal transition period is required for the student’s return to school, please detail the
transition calendar or steps for the transition here. [Note, the 504 Committee should complete a 504
Services Plan (Form 12) prior to the student’s return to school from homebound should the student
remain eligible upon his return to school.]
Additional documentation required for attendance accounting purposes:
General Education Homebound services begin on (date):
General Education Homebound services terminate on (date):
The teacher providing General Education Homebound instruction will maintain a log of contact hours and
other appropriate documentation related to the provision of these services. [See current Student
Attendance Accounting Handbook for more detail on documentation requirements.]
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HB Form #9
HUMBLE ISD
HOMEBOUND ATTENDANCE NOTIFICATION
Instructions:
This form is to be completed by the
Diagnostician/LSSP when the student is placed on Homebound.
To:
Attendance Clerk
From:
Counselor's Signature
Date:
Re:
Student's Name
*
I.D. #
Campus
The above student will be receiving Homebound services beginning
through
.
(approximate date of return)
Circle one of the following options:
1.
This student has a shortened school day and will attend school
Student will be counted absent if he/she does not attend at these times.
.
2.
This student attends school for a designated number of days per week. Specify days per
week
. Student will be counted absent if he/she does not attend on
these days.
3.
This student should be counted present for the entire period of time he/she is served on
Homebound unless absences are reported by the homebound teacher. The official date of
return is when the student checks back into school with a signed “Physician's Release of
Homebound Services” form. This should not occur without first having an ARD/504
meeting to dismiss student from Homebound services.
* The Homebound services begin with the date indicated by the ARD/504 committee.
Copies are distributed to:
Diagnostician for Audit folder
Counselor/for PRC folder
Attendance Clerk
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HOMEBOUND TEACHERS PACKET
a. Homebound Teacher Responsibilities
b. Family Responsibilities
c. Home Instruction Assignment Record – HB Form #10
d. Instructional and Related Service Attendance Record – HB Form #11
e. Homebound Attendance Log – HB Form #12
19
HUMBLE ISD
RESPONSIBILITIES OF TEACHERS PROVIDING
HOMEBOUND SERVICES
1.
Discuss in the ARD/504 committee decisions regarding student’s assignments, tests, and
how grade will be determined.
2.
Establish initial contact with parents.

Introduce self

Coordinate times for instruction

Explain that an adult must always be present during instruction

Explain the requirement of an appropriate place for instruction in the home

Discuss parent responsibility information and give parents a copy.
3.
Deliver assignments, tests, and materials to the student.
4.
Provide instruction, explain assignments, and administer tests to students.
5.
Report any problems to the student’s case manager/counselor.
6.
Encourage parents to monitor study activities closely.
7.
Inform parents of the student’s academic progress.
8.
Update IEPs and/or provide progress report input.
9.
Maintain attendance records of student and provide a copy to campus case manager/
counselor and attendance clerk.
10.
Return to special education coordinator and Student Support Services office professional
time sheets for Homebound Services every two weeks (if applicable).
11.
Homebound teacher will inform parent when unable to provide services at designated time
due to illness, workshops, etc. Teacher and parent will work to reschedule visit to provide
services.
rev 02/2013
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HUMBLE ISD
RESPONSIBILITIES OF FAMILIES OF STUDENTS
RECEIVING HOMEBOUND SERVICES
Instructions: This form is discussed in the ARD/504. It is reviewed
again on the first day of Homebound services.
Humble I.S.D. will provide a Homebound teacher to work with your child at home until he/she is able to
return to school. Your child will receive instruction as per ARD/504 agreement.
In order for your child to receive appropriate services from this program, families must adhere to the
following requirements:
1.
An adult must be present in the home during each instructional session. The Homebound teacher
cannot enter the home without an adult present.
2.
Provide a table for the student and teacher to use.
3.
Provide a smoke free, clean environment that is conducive to learning.
4.
Ensure uninterrupted class and study periods.
5.
Have books and materials ready.
6.
Provide appropriate assistance to your child in completing assigned work. Assignments must be
completed within a designated time frame.
7.
Notify the teacher 24 hours prior to canceling a scheduled instruction session. Any canceled
session that is not made up within a week will count as an absence.
8.
Notify the teacher before visit if anyone in the home has a contagious condition, a temperature
above 102º, or an infection of any kind.
9.
Contact the campus nurse when school placement is considered. Students will not be readmitted without a signed Physician's Release of Homebound Services Form. An ARD/504
meeting must be scheduled before re-entering school.
10.
A Physician's Continuation of Homebound Services form must be completed to extend
services beyond the original date. Extension of services must be reviewed by the Coordinator of
Health Services and approved by the ARD/504 committee.
rev 02/2013
21
edu-supp\g&c\homebound\packet.doc
HB Form #10
HUMBLE INDEPENDENT SCHOOL DISTRICT
HOME INSTRUCTION ASSIGNMENT RECORD
Student ID #
Name of Student
School
Grade
Name of teachers/courses:
Name of Homebound teacher:
DATE
rev 02/2013
VISIT TIME
(i.e. 10am12pm)
ASSIGNMENT
DATE DUE
22
COMPLETED
DATE/TIME
PARENT
SIGNATURE
DATE
RETURNED
TO HOME
CAMPUS
edu-supp\g&c\homebound\packet.doc
HB Form #11
HUMBLE ISD
INSTRUCTIONAL & RELATED SERVICES ATTENDANCE RECORD 2012-2013 SCHOOL YEAR
Student
DOB:
Teacher:
Campus:
Guardian
Eligibility
Grade:
Contact Info:
Date of Last Evaluation
Date Annual ARD
District Equipment Used:
M
T
3
Notes:
T
F
M
T
W
T
F
M
T
W
T
F
M
T
W
T
F
M
T
W
T
F
1
2
3
6
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28
29
30
31
S
S
S
S
S
SEM
4
5
6
7
10
11
12
13
14
17
18
19
20
21
24
25
26
27
28
2
3
4
5
8
9
10
11
12
15
16
17
19
22
23
24
25
26
30
31
30
H
OCT
1
ED
SH
NOV
1
18
3
4
5
6
ED
2
5
6
7
8
9
12
13
14
15
16
19
H
H
H
H
H
7
10
11
12
13
14
17
18
19
20
21
24
25
26
27
28
ED
JAN
1
2
3
4
H
H
H
H
7
29
ED EGP
ED
DEC
3 Year Evaluation:
W
AUG
SEPT
Teacher;
8
ED
SEM
20
21
22
23
26
27
28
29
31
31
H
H
H
H
H
H
9
10
11
14
15
16
17
18
21
22
23
24
25
28
29
30
SH SEM
H
ED
FEB
1
4
5
6
7
8
11
12
13
14
15
18
19
20
21
22
25
26
27
MAR
1
4
5
6
7
8
11
12
13
14
15
SH
18
19
20
21
22
25
26
27
APR
1
2
MAY
28
29
ED
H
H
H
H
H
3
4
5
8
9
10
11
12
15
16
17
18
19
22
23
24
25
26
29
30
1
2
3
6
7
8
9
10
13
14
15
16
17
20
21
22
23
24
27
28
14
17
18
19
20
21
24
25
26
27
28
28
EGP SH
29
30
H
31
ED
JUN
3
4
5
6
7
10
11
12
13
ED
SEM
H
SEM
SH
ST
elm
Holiday
Beg/End Semester
Student Holiday
State Mandated Testing
End of 9wk period
rev 02/2013
sec
#hrs
C
D
SA
End of 6wk period
Therapy received
Consult
Direct
Student Absent
ARD
SU
TA
T*
P
23
Student ARD
Student unavailable
Therapist Absent
Therapist at in-service/ARD
Therapy pending MD approval
E
ED
MU
S
Equipment modification or check
Early dismissal for elementary
school
Makeup day
Staff development day
edu-supp\g&c\homebound\packet.doc
HB Form #12
Homebound Attendance Log 2012-2013
Student Name:
Student ID:
Grade:
Campus Name and Building #:
ADA Eligibility – Full day, half day, non membership:
Homebound Program – General Ed or Special Ed:
Teacher’s Name (Print please):
Week’s
Week’s
Beginning
Ending
Date
Date
Sample Below
8/27/2012
8/31/2012
Total Contact
Hours per week
Record of Contract Hours Served
M
0.0
T
1.0
W
1.0
R
2.0
F
0.0
4.0
TOTAL CONTACT HOURS
Teacher’s Signature:
Date:
This log should be emailed to the campus attendance office each week. A copy of the signed original must be sent interoffice
to the campus attendance office at the end of 6 weeks reporting period.
General Ed Homebound: At the end of each six weeks reporting period, the signed original must be sent to the home campus
and retained by the attendance office for audit purposes.
Special Ed Homebound: At the end of each six weeks reporting period, the signed original must be sent to and retained by
the Special Ed Office for audit purposes.
Homebound Funding Chart
Eligible Days Present
Amount of Time Served per Week
Earned per Week:
1 hour
one day present
2 hour
two days present
3 hour
three days present
4 or more hours
five days present (5-day week)
Homebound Teacher Instructions: At the end of the week, certified staff should inform the attendance clerk of the amount of
time the student received from the certified teacher and the number of absences that should be recorded in the attendance
accounting system.
Example A: The student was served for 4 or more hours that week, the student should be counted present everyday that
week.
Example B: The student was served for 2 hours that week, the student should be recorded present for 2 days and absent for 3
days if he is full-day eligible student.
Example C: The student does not receive any homebound services for that week, he should be marked absent every day that
week.
rev 02/2013
24
edu-supp\g&c\homebound\packet.doc