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ORLEANS PARISH SCHOOL BOARD STUDENT EVALUATION AND SUPPORT SERVICES 3520 General DeGaulle Drive New Orleans, Louisiana 70114 Phone: 304-4988 Fax: 309-4158 Medical information is needed for the following student in order to determine if there are HEALTH IMPAIRMENTS sufficient to warrant special education services. Please check appropriate behaviors and provide a simple explanation when indicated: Name: ______________________________________________ DOB: __________________ Name of Parent(s): ______________________________________________________________ Address: ______________________________________________________________________ ______________________________________________________________________ ****************************************************************************** Diagnosis: _____________________________________ Date last seen: _________________ Severity of illness: ___mild Condition causes

___moderate

___severe

___ reduced efficiency in school work because of ___temporary or chronic lack of strength ___temporary or chronic lack of vitality ___temporary lack of alertness

Student is substantially limited in the following major life activity/activities: ___ caring for one’s self

___seeing

___working

___performing manual tasks

___hearing

___walking

___breathing

___speaking

___learning

Other major life activity: _____________________________________________ ___This condition significantly interferes with educational performance in the following way(s): ______________________________________________________________ Student may need: ___Adapted Physical Education

___OT

___PT

___Speech

Specify the medical implications for instruction and for physical education: _____________________________________________________________________________________ _____________________________________________________________________________________ Physician’s Signature: ________________________________________ Date: _____________ Please return to: _______________________________ Evaluation Coordinator Exceptional Children’s Services 9/11


request-for-medical-health-impairment