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Includes two sections: school-district information and physician/APRN/PA completion, covering diagnosis, treatment categories, communicability, impact on school attendance, program selection (home instruction or hospital class/bedside), estimated duration, and special recommendations for staff.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/medical-certification-for-home-hospital-instruction-instructions-and-form/537261/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-certification-for-home-hospital-instruction-instructions-and-form/537261.png","ImageObject",300,407,{"name":42,"@type":43},"Danger Angel","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-10","2026-10-10",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"When can a student be eligible for home or hospital instruction?","Question",{"text":63,"@type":64},"A student may be eligible when a medical condition (physical or mental) requires the student to be away from the school building for a minimum of two or more consecutive weeks, or for ongoing intermittent absences totaling 10 or more school days. The qualified teacher provides instruction at home or in a hospital (or other setting).","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Where should the completed medical certification form be submitted?",{"text":68,"@type":64},"The completed form must be returned to the local school district promptly. It should not be submitted to the State Board of Education, and it must be made available for auditing purposes.",{"name":70,"@type":61,"acceptedAnswer":71},"What information must the physician/APRN/PA complete in Section 2?",{"text":72,"@type":64},"Section 2 requires diagnosis and related details, including whether a disease is communicable, treatment and pregnancy categories, mental/emotional health, other descriptions, and the impact on the student’s ability to attend school. It also requires certification of medical eligibility, program selection (home instruction or hospital class/bedside), estimated duration (at least 10 school days this year), special recommendations, and the provider’s signature and date.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},537261,1791737555,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},"Religion & Spirituality",20,"religion-spirituality",{"id":117,"doc_module":4,"doc_module_name":25,"category_name":120,"show_sort_weight":117,"slug":121},"World Cup","world-cup",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":123,"slug":125},10,"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":30,"preview_page_count":4},962090769052,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Use your \"Mouse\" or \"Tab\" key to move through the fields and check boxes. After completing last field, save document to hard drive to make future updates or click Print button.   \nMEDICAL CERTIFICATION FOR HOME /  \n  HOSPITAL INSTRUCTION  \n100 North First Street  \nSpringfield, Illinois 62777-0001  \nINSTRUCTIONS: Complete this form and retain on file in the local school district. Do not submit this form to the State Board of Education, but make this form available for auditing purposes.  \nStudents may need to be educated temporarily away from the school building due to a medical condition (physical or mental) . When a student needs to be away from the school building for a minimum of two or more consecutive weeks of school or ongoing intermittent absences totaling 10 or more schooldays, the student may be eligible for instruction at home or in a hospital (or other setting) by a qualified teacher. (34 CFR 300.39 and 300.115 and Section 14-13.01 of the school code [105 ILCS 5/14-13 .01(a)] and ISBE Rule 226.300) . It is not necessary for the student to have an IEP or 504 plan to qualify, although either may be created depending on student need and school procedures.  \nParents: Please return this form to your child’s school district promptly as services cannot be started until medical information is received. Upon receipt of medical certification, the school district will provide home/hospital services for an eligible student.  \nSECTION 1 – THIS SECTION FOR SCHOOL DISTRICT USE ONLY  \n\n| NAME OF STUDENT (Last, First, Middle) | GENDER\u003Cbr> Male  Female | GRADE |\n| --- | --- | --- |\n| STUDENT ADDRESS (Street, City, State, ZIP Code) | NAME OF STUDENT PARENT OR GUARDIAN |  |\n| STUDENT DATE OF BIRTH | TELEPHONE OF STUDENT PARENT OR GUARDIAN (Include Area Code) |  |\n| DISTRICT NAME AND NUMBER | SCHOOL NAME |  |\n| DISTRICT ADDRESS (Street, City, State, ZIP Code) | SCHOOL ADDRESS (Street, City, State, ZIP Code) |  |\n| DISTRICT TELEPHONE (Include Area Code) | SCHOOL TELEPHONE (Include Area Code) |  |\n\nSECTION 2 – TO BE COMPLETED BY PHYSICIAN LICENSED TO PRACTICE MEDICINE IN ALL ITS BRANCHES, APRN OR PA:  \nDIAGNOSIS (Please fill in the following):  \nDisease/Injury/Surgery (Primary diagnosis)   If disease, is the disease communicable?  Yes  No If yes, please provide instruction to school staff in the space below labeled “Special Recommendation to Teachers”  \nDrug/Alcohol Treatment   Pregnancy (Including Postpartum)   Mental Health/Emotional Health   Other (Please describe)   Impact the diagnosed medical condition has on this student's ability to attend school:  \nI certify that this student is unable to attend public school and is medically eligible and physically able to be enrolled in the following program  \n\n| (Check (3) one only) |  Home Instruction  Hospital Class or bedside |  |  |\n| --- | --- | --- | --- |\n| The medical provider must estimate that the student will need the home or hospital instruction for a minimum of 10 school days this school year. The time may be longer than 10 days; if unable to determine approximate length of time, provider may estimate ‘through end of school year’ as long as the time period is at least 10 days. |  |  | Estimated length of time student will need home or hospital instruction this school year, if possible.\u003Cbr>(In weeks):   |\n| Special Recommendation to Teacher concerning diet, rest, exercise, positioning, etc. |  | Type or Print Name of Physician, MD, DO, APRN or PA\u003Cbr>Provider Contact Telephone Number (Include Area Code)\u003Cbr>Original Signature of Physician, APRN or PA Date |  |\n| SCHOOL DISTRICT USE ONLY:\u003Cbr>Date home or hospital instruction began:   |  |  |  |\n\nISBE 34-58 (4/23)  Print   Reset Form","cbCaib3d17NPTvbS","https://ap.wps.com/l/cbCaib3d17NPTvbS","pdf",326338,"English","# Section 1 - School District Use Only\n## Student information fields\n# Section 2 - Physician/APRN/PA Completion\n## Diagnosis and medical eligibility details\n## Program selection and estimated duration\n## Special recommendations and provider signature","[{\"question\":\"When can a student be eligible for home or hospital instruction?\",\"answer\":\"A student may be eligible when a medical condition (physical or mental) requires the student to be away from the school building for a minimum of two or more consecutive weeks, or for ongoing intermittent absences totaling 10 or more school days. The qualified teacher provides instruction at home or in a hospital (or other setting).\"},{\"question\":\"Where should the completed medical certification form be submitted?\",\"answer\":\"The completed form must be returned to the local school district promptly. It should not be submitted to the State Board of Education, and it must be made available for auditing purposes.\"},{\"question\":\"What information must the physician/APRN/PA complete in Section 2?\",\"answer\":\"Section 2 requires diagnosis and related details, including whether a disease is communicable, treatment and pregnancy categories, mental/emotional health, other descriptions, and the impact on the student’s ability to attend school. It also requires certification of medical eligibility, program selection (home instruction or hospital class/bedside), estimated duration (at least 10 school days this year), special recommendations, and the provider’s signature and date.\"}]","MEDICAL CERTIFICATION FOR HOME - HOSPITAL INSTRUCTION - Instructions and Form | PDF",1791604292]