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Procedures for S ett in g u p a omebound o sp i ta lProgramA Hospital/Homebouncl Program requires good communication cooperation

nd coll bor tion between the school p rents nd the tutor1 Convene a meeting to document the reason the program is needed

Identify a d is tr ic t c on ta ct person Case Manager) wh o will beresponsible f or m an ag in g the HHB programStudent will be absent more than 10 consecutive school daysObtain a medical certificate authorizing the r ea so n a nd anticipatedlength attached)Complete Home/Hospital Instruction Request FormIdentify goals to be accomplished as a result o f providing thep ro r m

Determine maximum number of hours per week u sually 5-10depending on age and ability to work on academic tasks)Secure parent c o n s e n t an d releases if n eed ed )omplete a F CTS sheet nd send to L DSE to the ttention of rrie ervenk

2 Determine who will provide the tutoring or related services If L DSE call Lynn Krai to secure a tutor If d is tr ic t p e rs on , c o nt ac t with c o nf e re n ce r e co r d o r IEP Set u p c o mm u n ic a ti o n plan between home-tutor-school

3 Prepare staf f for return o f the student Work should be corrected by th e tutor, but graded by th e teacher Consider any necessary accommodations shortened day, accessibility

issues, required medication o r s id e e ff ec ts ) Make s u re t ea c h er s are aware o f s tu d en t s return d a t e omplete F CTS sheet to indicate the end of the service

4 Parent ResponsibilitiesAn adult must be present at all times when the tutor is in the homeIt is th e responsibility of the parent to make s ur e t he home address isvisible and the home is accessible clear sidewalk of snow, ice, etc.Contact the tutor in a timely manner if student is unavailable fortutoring

Please call Lynn Kraiat L DSE 708 354 5730 if you have any questions

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rent Responsibi l i t i es for omebound Tu to r i ng rogram

An adult must be present at aN times when the tutor is int om

It is the responsibility of the parent to make sure the homeaddress is visible and entrance to the home is safelyaccessible clear sidewalk of snow, ice, etc.Please provide a smoke-free environment for our L SEtut s

Have school books and supplies ready when tutor arrives Secure any pets; provide a safe and quiet work area, in order

to promote an environment free of distraction Contact the tutor in a timely manner if student is

unavailable for tutoring

Please contact Lynn rai at L DSE 7 8 354 573 if you have any questions

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LAGRANGE AREA DEPARTMENT OF SPECIAL EDUCATION13 1 s t Cossitt AvenueLaGrange, 6 525

MEDICAL REFERRAL

STUDENT NAME AGE/GRADE.SCHOOL DISTRICTSERVICES RECOMMENDED:

Home Tutoring Hospital TutoringApproximate length of time pupil will need special services:.Diagnosis:

Relevant History positive physical findings, surgery, etc.

Special precautions, suggestions or instructions:

Date of last examinat ion:Parents home phone number:Parents emergency number:_

Physician Signature.Physician Address_Physician Phone

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LADSE The LaGrange rea Department of Special ducation1301 W.Cossitt LaGrange, IL 60525Phone: 708354 5730 Fax:708 354 0733 TTY: 708 352 5994www.ladse.org

Dr.Sheri WernsinE x e c u t i v e D i r e c t

Home/Hospital Instruction Request Form

Student s N a m e : .Address:City:

Birth D a t e :

Parent s)/GuardianN a m e :

Zip:.

H o m e P h o n e : W o r k P h o n e :

R e s i d e n t District:

School C o n t a c t Person:.N a t u r e o f Illness:

R e s i d en t S c h o ol :

P h o n e :

Hours per week* 2 hrs. prep time for every 5 hours tutored):Approved by:Start Date: Planned Stop D at e:P l e a s e c h e c k o n e :RegularEducation: / Special Education: A d d i t io n a l I n f o rm a t i o n :

hours a w hour a day or standard

Supporting education for ail children in th e community school districts: Butler 94 Komarek 2 LaGrange61 Darien 95 8rookfield-LaGrangePark 105 Lyons62 Gower 96 Riverside 105 LaGrange South9 : W e s t c he s t e r 101 Western Springs 106 LaGrangeHighlands

G r a d e :

10 7 Pl e a s a nt da l e86 Hinsdale Township HighSchool

204 LyonsTownship High School20 8 Ri ve r si d e Br oo k fi e ld Hi qh Sc h oo l