<p> HOMEBOUND AND HOSPITALIZATION INSTRUCTION VERIFIED MEDICAL REASON</p><p>TO THE TREATING PHYSICIAN: Pursuant to the Connecticut State Department of Education regulations (specifically R.C.S.A. §10-76d-15), the following information must be provided to the district in order for a student to be eligible for homebound instruction. Please legibly complete this form. If you have any questions about this form, please contact Ishrat Quadri, M.D. Wethersfield Schools Medical Advisor @860-235-3084.</p><p>Name of Child: ______Date of Birth: ______</p><p>Address of Child: ______</p><p>Name of Parent(s)/Guardian: ______</p><p>Address of Parent(s)/Guardian:______</p><p>The section below must be completed by the student’s treating physician to verify a medical reason that prohibits the student from attending school. Upon completion, this form must be provided by the treating physician directly to the Wethersfield Public Schools, care of Chlo-Anne Bobrowski, MSN, RN, Head Nurse, at Charles Wright School, 186 Nott Street, Wethersfield, CT 06109.</p><p>Contact Information for Treating Physician</p><p>Name: ______</p><p>Address: ______</p><p>Phone: ______Fax: ______Email: ______</p><p>Medical Verification</p><p>Yes No</p><p>□ □ I have consulted with school health supervisory personnel and have determined that the child’s attendance at school with reasonable accommodations is not feasible.</p><p>□ □ The above-named child is unable to attend school due to a verified medical reason.</p><p>□ □ The child will be absent from school for at least ten (10) consecutive days.</p><p>□ □ The child will be absent from school for short, repeated periods of time during the school year. </p><p>The child has been diagnosed with: ______</p><p>______</p><p>______</p><p>______</p><p>*Documentation supporting the above diagnosis MUST be submitted to the Wethersfield Public Schools along with the Medical Verification Form.</p><p>The child is expected to be able to return to school on: ______</p><p>By signing below, I verify that the above information is accurate to the best of my professional knowledge. </p><p>______Signature of Treating Physician Date</p>
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