Request for Home & Hospital Instructional Services

CENTINELA VALLEY UNION HIGH SCHOOL DISTRICT REQUEST FOR HOME & HOSPITAL INSTRUCTIONAL SERVICES

Any pupil with a temporary illness or injury, which makes attendance in regular day classes or an alternative education program impossible or inadvisable, may receive Home & Hospital (H&H) instructional services. Instruction in the Home & Hospital Program is provided by the Centinela Valley Union High School District.

The Centinela Valley Union High School District Home & Hospital Program is designed to provide instructional continuity to students who are unable to attend their regular school of attendance due to major surgery/traumatic injury; cancer/chemotherapy; chronic health impairment; or, other debilitating health conditions.

To qualify for Home & Hospital instructional services, the student’s illness or injury must be diagnosed and verified in writing by a licensed physician, clinical psychologist, or psychiatrist. The term “temporary disability” means disabled by accident or by physical, mental, or emotional illness for a period of four (4) weeks or longer.

Home & Hospital instruction is a short-term service mandated by State law with specific guidelines for program implementation and delivery, as detailed in the California Education Code referenced below:

California Education Code 48206.3 (a) Except for those pupils receiving individual instruction is provided pursuant to Section 48206.5, a pupil with a temporary disability which makes attendance in the regular day classes or alternative education program in which the pupil is enrolled impossible or inadvisable shall receive individual instruction provided by the district in which the pupil is deemed to reside.

(b) For purposes of this Section and Sections 48206.5, 48207, and 48208, the following terms have the following meaning:

(1) “Individual instruction” means instruction is provided to an individual student in the student’s home, in a hospital or other residential health facility, excluding state hospitals, or under other circumstances prescribed by regulations adopted for that purpose by the State Board of Education.

(2) “Temporary disability” means a physical, mental, or emotional disability incurred while a pupil is enrolled in their home school regular program or alternative education program, and after which the pupil can reasonably be expected to return to regular day classes or alternative education program without special intervention. A temporary disability shall not include a disability for which a pupil is identified as an individual with exceptional needs pursuant to Section 56026.

In considering the needs of students with chronic illnesses or with medical conditions that are reasonably likely to require hospitalization and/or extended absences, home teaching services will be made available in an effort to support the student’s instructional program until they are able to return to school. A Home & Hospital teacher provides instruction in subjects/courses correlated with the student’s school program to the greatest extent possible.

Home & Hospital Instruction is designed as a temporary service, with the intent to maintain continuity of the student’s instructional program during the interim period of disability; however, the health recovery of the student takes first priority, with school being secondary. While home instruction will help the student progress academically, it is important to understand that student performance may not be equal to that demonstrated while participating in the regular school day program. Therefore, balancing educational achievement and wellness/recovery is a constant challenge for students, teachers, and parents, which cannot be overlooked or minimized. To that end, Home & Hospital does not replace, over an extended period of time, the regularly required instructional program. REVISED 10/7/2015 CENTINELA VALLEY UNION HIGH SCHOOL DISTRICT REQUEST FOR HOME & HOSPITAL INSTRUCTIONAL SERVICES

CENTINELA VALLEY UNION HIGH SCHOOL DISTRICT REQUEST FOR HOME & HOSPITAL INSTRUCTIONALSERVICES SOLICITUD PARA SERVICIOS DE INSTRUCCIÓN EN EL HOGAR Y HOSPITALARIOS

STUDENT INFORMATION INFORMACIÓN DEL ESTUDIANTE Last Name Apellido: First Name Primer Nombre: Student ID # Número de Identificación Estudiantil:

School Escuela: Grade Grado Escolar: Birth Date Fecha de Nacimiento: HW LW LZ LL 9th 10th 11th 12th

School and Specialized Education Programs The student is receiving or has received services in (please check all that apply): Escuela o Programas de Educación Especializada El estudiante está recibiendo o ha recibido servicios en (favor de marcar todo lo que aplique):

504 Plan Special Education Educación Especial (IEP) English Language Development Desarrollo del Idioma Ingles (ELD)

PARENT/LEGAL GUARDIAN INFORMATION AND SIGNATURE INFORMACIÓN Y FIRMA DEL PADRE/TUTOR

Last Name Apellido: First Name Primer Nombre: Phone Teléfono: Cell Celular Home Casa Work Trabajo

Address Domicilio: City Ciudad: Zip Código Postal: Email Correo Electrónico

As the parent/legal guardian, I authorize CVUHSD and the physician(s) identified below to release and exchange medical information relative to the above named student so eligibility for Home & Hospital instructional services can be determined. Como padre/tutor legal, autorizo a CVUHSD y al médico(s) identificados a continuación de liberar e intercambiar información médica relativa al estudiante mencionado arriba para que la elegibilidad de servicios de instrucción en el Hogar y Hospitalarios se puedan determinar.

Parent/Legal Guardian Signature Firma del Padre o Tutor: (Required Necesario) Relationship to Student Relación: Date Fecha: PHYSICIAN//PSYCHIATRIST/CLINICAL PSYCHOLOGIST’S RECOMMENDATION AND CERTIFICATION RECOMENDACIÓN Y CERTIFICACIÓN DEL MEDICO/PSICÓLOGO CLÍNICO/ PSIQUIATRA

REVISED 10/7/2015 The information received will be used to assist CVUHSD in determining eligibility for Home & Hospital instructional services for this student. All information will be kept confidential and shared only upon parent/legal guardian authorization. Processing requires ALL information below. Incomplete certifications will be returned for completion. A specific medical, emotional, or psychological diagnosis must be provided for this student in order to be considered for Home & Hospital instructional services.

Medical Diagnosis______Prognosis and Extent of Limitation______

Does this student have a contagious disease or a medical condition that poses a risk to district staff? YES NO

Will this student be unable to attend school for at least four weeks? YES NO

Is this student able to leave the home for one hour per week to attend Independent Study School YES NO instead of receiving Home & Hospital instructional services? Could this student benefit from a shortened or modified school day instead of receiving YES NO Home & Hospital instructional services? If yes, please indicate limitations that would exist and recommended modifications or accommodations______I certify that the student is confined to a medical facility or his/her residence which prevents him/her from attending school for any period of time. He/she is medically able to study, learn, and complete assignments. I understand that placement of the student on Home & Hospital instructional services is at the discretion of CVUHSD and that the medical need must be re-certified at least every 8 weeks. Home & Hospital Begin Date Home & Hospital Projected End Date

Medical Professional’s Name (STAMP) Medical Professional’s Signature: Date:

Phone: (include area code) Fax Number: Email:

CENTINELA VALLEY UNION HIGH SCHOOL DISTRICT REQUEST FOR HOME & HOSPITAL SERVICES SOLICITUD DE INSTRUCCIÓN EN EL HOGAR Y HOSPITALARIOS

SITE RECOMMENDATION RECOMENDACIÓN DEL PLANTEL ESCOLAR As the counselor, I recommend the following placement and have included an up-to-date graduation checklist and a list of courses that must be completed during the current and/or upcoming term.

Home & Hospital Instructional Services CVISS Short Term Independent Studies Other:______

Recommended Courses for the current or upcoming Home & Hospital term: Comment: 1.______2. ______3. ______4. ______5. ______6. ______7. ______8. ______

Counselor Signature/Firma del consejero/a: Date/Fecha:

Administrator Signature/Firma del Administrador: Date/Fecha:

REVISED 10/7/2015 DISTRICT SCHOOL NURSE RECOMMENDATION RECOMENDACIÓN DE LA ENFERMERA ESCOLAR DEL DISTRITO Recommendation: Home & Hospital Instructional Services CVISS Short Term Independent Studies Other:______

Comment:

District Nurse Signature/Firma de la Enfermera del Distrito: Date/Fecha:

DISTRICT ADMINISTRATION AUTHORIZATION AUTORIZACIÓN DE LA ADMINISTRACIÓN DEL DISTRITO H&H Authorizing Signature (Office of Student Services): Decision : Date: APPROVED

DENIED Comment:

H&H School H&H Start Date H&H End Date HW LW LZ LL

H&H Teacher H&H Counselor

REVISED 10/7/2015