Family Information Notebook (FIN) - Vanderbilt Kennedy Center

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Family Information Notebook (FIN)
fin (fĭn) n. 1. a fish uses its fin to balance, steer, and avoid obstacles as it
moves through the water. This FIN will help your family move, steer, and
keep balance as you work with others in your community who help care
for your child.
FIN stands for Family Information Notebook , it is designed to help you coordinate
many aspects of your child’s care and health (i.e.: doctors, dentist, therapists,
services agencies and various forms). It can help you and others caring for your
child exchange information so your child’s special health care needs can be met
appropriately. You may share copies of any part of your notebook with anyone who
works with your child, including family members and friends. The FIN is designed to
be as comprehensive as possible, we hope that the notebook will serve as a
detailed record of your child’s health history that he or she may access throughout
adulthood.
If you need additional forms they are available for download on the Internet at:
www.kc.vanderbilt/FIN. Some additional forms relating to specific medical conditions
(asthma, cardiac disorders, diabetes, Down syndrome, seizure disorders, severe
allergic reactions, and sickle cell anemia) are available at: www.finonline.org. If you
do not have Internet access, all forms are available free of charge at the Junior League
Family Resource Center (see next page for contact information) and through the
Vanderbilt Kennedy Family Outreach Center at: (615) 936-5118.

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The Fin Notebook is made possible
Need assistance or further information? We are happy to help!
If you have any questions, need additional paper copies of the forms, or
would like help working with the FIN notebook or the FIN website, please
feel free to contact us:
Junior League Family Resource Center
Vanderbilt Children’s Hospital
2200 Children’s Way, Suite 2125
Nashville, TN 37232-9200
Phone: (615) 936-2558 or Toll Free: (800) 258-0391
Fax: (615) 936-2561
Email: family.frc@vanderbilt.edu
Website: www.vanderbiltchildrens.com/fin
© Junior League Family Resource Center 2005

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TABLE OF CONTENTS
Emergency Health Information ............................................................... 4
Health and Development ....................................................................... 15
Daily Routine .......................................................................................... 24
Education / School Records ................................................................. 36
Resources / Optional Forms ................................................................. 44
Appendices ............................................................................................. 65

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Emergency Health Information
• Introduction to Emergency Health Information Section 5
• Forms:
� Emergency Contact Information 6
-- Important Phone Numbers
-- Communication and Ways to Communicate
� Medical Information: 7
-- Current Providers
-- Current Diagnoses and Conditions
� Medications 8
� Baseline Data 9
� Surgery or Procedure Record and Hospital Admissions 10
� Allergies 11
� Latex Allergy Information 12
� Medical Power of Attorney 13
� Suggested Information to Include: 14
-- Emergency Protocol from Doctor
-- Insurance Information
-- Custody Papers
-- Discharge Summaries if Available
-- Advance Care Plan
© Junior League Family Resource Center 2005

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INTRODUCTION TO EMERGENCY HEALTH INFORMATION SECTION
This section provides information that you or another caregiver might need if there is a medical emergency
with your child. It includes:
Emergency Contact Information: to provide you or another caregiver with information
on how to get in touch with the parents / guardian of your child and how to contact
services that may be needed in the event of an emergency. Also included is your family’s
primary ways of communicating.
Medical Information: pages to show all doctor providers, diagnoses and conditions.
Medications: past and present.
Baseline Data: significant information about vital signs, labs and tests, prostheses and
technological devices, x-rays, and major body systems.
Surgeries and Procedures: to record the surgeries and procedures your child has had
and when and where the surgeries and procedures took place. The form also provides
information on when and why your child has been hospitalized for non-surgical reasons.
Allergies: to keep track of any drug, herb, food, fabric, animal, latex, and plant allergies
your child may have.
Latex Allergy Information: explains how latex exposure may occur.
Medical Power of Attorney: to give permission for other people you choose to
authorize medical treatment for your child.
Suggested Information to Include:
-- Emergency Protocol from Doctor (Copy)
-- Insurance Information: provide copies of your insurance card(s) and policy
numbers, including any TennCare information
-- Custody Papers
-- Discharge Summaries (if available)
-- Advanced Care Plan

CHILD’S NAME: DATE OF BIRTH:
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EMERGENCY CONTACT INFORMATION
Contact Parent / Guardian:
Name: Relationship:
Daytime number: Cell phone:
Other means of contact:
Name: Relationship:
Daytime number: Cell phone:
Other means of contact:
Other contact (Relative, neighbor):
Name: Relationship:
Daytime number: Cell phone:
Other means of contact:
Name: Relationship:
Daytime number: Cell phone:
Other means of contact:
Electricity Company:
Poison control:
Gas Company:
Security Company: __________________
Pediatrician’s emergency/after-hours contact number: ______________________
Preferred Hospital: __________________________________________________
Special Equipment/Medical Supplier:
Company Phone Number
______________________________ _______________
______________________________ _______________
COMMUNICATION AND WAYS TO COMMUNICATE
DOES YOUR
CHILD SPEAK? YES NO
IS YOUR CHILD:
VERBAL
NON-
VERBAL
IS YOUR CHILD
HEARING
IMPAIRED: YES NO
WHAT LANGUAGE DOES YOUR CHILD SPEAK?
ENGLISH SPANISH OTHER
IF OTHER, WHAT LANGUAGE/TYPE OF INTERPRETER?
IS YOUR CHILD
LEGALLY
BLIND? YES NO
Signature of Parent or Guardian Relationship to child Date

CHILD’S NAME: DATE OF BIRTH:
CURRENT PHYSICIANS:
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MEDICAL INFORMATION
PRIMARY CARE PHYSICIAN: EMERGENCY PHONE:
FAX:
SPECIALTY PROVIDERS: EMERGENCY PHONE:
FAX:
SPECIALTY PROVIDERS: EMERGENCY PHONE:
FAX:
SPECIALTY PROVIDERS: EMERGENCY PHONE:
FAX:
SPECIALTY PROVIDERS: EMERGENCY PHONE:
FAX:
CURRENT PHARMACY:
PHARMACY: PHONE NUMBER:
CURRENT DIAGNOSIS AND CONDITIONS
DATE
RECEIVED
DATE
RECEIVED
FAX:
© Junior League Family Resource Center 2005

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NAME OF MEDICATION
CHILD’S NAME: DATE OF BIRTH:
STRENGTH
(SEE LABEL)
REASON FOR
MEDICATION
MEDICATIONS
DOSAGE /
FREQUENCY
/AMOUNT
ROUTE
(HOW TAKEN)
© Junior League Family Resource Center 2005
START DATE END DATE
MO DAY YR MO DAY YR
REASON FOR
ENDING
MEDICATION

CHILD’S NAME: DATE OF BIRTH:
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BASELINE DATA
NORMAL VITAL SIGNS:
Pulse rate: _________________ Site best taken: _______________________________________
Blood pressure: _____________ Site best taken: _______________________________________
Temperature: _______________ Site best taken: _______________________________________
Respiratory Rate: _________ per minute Skin color: ___________________________
Oxygen Saturation: ________________________________
Pupils (normal, dilated, constricted, equal): _____________________
Blood draw site: ____________________________________________________________
SYSTEMS (BASELINE DATA)
CNS / Sensory
Heart / Blood (Include recent
blood counts)
Gastrointestinal
Respiratory (describe
breathing sounds)
Genitourinary
Musculoskeletal
Baseline X-ray findings
Developmental
Labs
Prosthesis / Appliances/
Technological Devices
Others
OKAY
b
PROBLEM
b
COMMENTS/DESCRIPTION
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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SURGERY OR PROCEDURE RECORDS
TYPE OF SURGERY/PROCEDURE SURGEON PHYSICIAN HOSPITAL DATE
HOSPITAL ADMISSIONS (FOR REASONS OTHER THAN SURGERY)
REASON FOR ADMISSION HOSPITAL DATE (S)
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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ALLERGIES
MEDICATIONS/FOODS TO BE AVOIDED REACTION/WHY?
MEDICATIONS
LATEX
FOOD(S)
DYE
OTHER
INSECTS
PROCEDURES TO BE AVOIDED OR CONSIDERED
© Junior League Family Resource Center 2005

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LATEX ALLERGY
Latex exposure may occur through:
• direct contact with latex products
• indirect contact (a provider touching a latex product and then touching a patient)
• inhalation of airborne latex particles
• injection of materials through latex IV ports
ITEMS CONTAINING LATEX
adhesive tape diaphragms rubber balls
air mattresses elastic bandages rubber bands
baby bath toys erasers rubber boots
balloons eye cups on binoculars rubber cement
balls eye cups on cameras rubber gloves
Band-Aids foam pillows rubber stamps
bathing caps foam rubber rubber bottom shoes
belts for clothing Halloween rubber masks rubber anything
beach shoes pacifiers shower caps
bottle nipples paint sneakers
chewing gum teething rings stretch fabrics
condoms racquet handles telephone cords
crib mattress pads raincoats/slickers underwear
MEDICAL PRODUCTS CONTAINING LATEX
Ace wraps (brown tensor) latex gloves
blood pressure cuffs IV ports
inner bladder and tubing red rubber anything
syringes (rubber stoppers) rubber stoppers on multi-dose vials
tourniquets rubber bands
bulb syringes stethoscope tubing
catheters syringe plungers
electrode pads
face masks (rubber)
wheelchair tires
tape (adhesive, butterfly closure, & moleskin)
LATEX-FREE MEDICAL PRODUCTS
Ace wraps (white) Tegaderm
silk tape
steri-strips
EKG pads
(Red Dot - 3M and Baxter)
© Junior League Family Resource Center 2005

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MEDICAL POWER OF ATTORNEY
I, _____________________________________________________________, do give
(Name of Parent or Guardian)
permission for the following people to make decisions regarding medical treatment for
my child, ______________________________________________, should the need arise.
(Child’s Name)
Power of Attorney is given for emergency medical and dental care, including anesthesia
when it is needed. This consent is effective from this date and remains active until the
date indicated here, unless otherwise revoked:
Name:
Address:
Phone:
Beeper:
Name:
Address:
Phone:
Beeper:
Name:
Address:
Phone:
Beeper:
NOTARY
Parent name:
__________________
(Date)
Parent signature:
Notary name:
Date
Notary signature:
seal here Date
© Junior League Family Resource Center 2005

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SUGGESTED INFORMATION TO INCLUDE
� Emergency Protocol from Doctor
� Insurance Information
� Custody Papers
� Advanced Care Plan
� Discharge Summary (if available)
© Junior League Family Resource Center 2005

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Health and Development
• Introduction to Health and Development Section 16
• Forms
� Milestones 17
� Concerns about my child’s development 18
� Evaluations: 19-20
-- Eye
-- Hearing
-- Dentist
-- Speech / Language
-- OT / PT
-- Child Development
-- Psychiatry
� Family / Social Information 21
� Information for Genetic Family Tree 22
� Suggested Information to Include: 23
-- Immunization Records provided by pediatrician / PCP
-- Growth Charts
-- Genetic Family Tree if available
-- Genetic Test Results
© Junior League Family Resource Center 2005

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INTRODUCTION TO HEALTH AND DEVELOPMENT SECTION
This section of the notebook contains information on the medical condition of your child. It includes:
Milestones: indicates some of the things your child has achieved and the dates of these
achievements and gives a place to list your child’s special talents and skills.
Concerns About My Child’s Development: provides a list of concerns or
questions you may have about your child’s growth or development.
Evaluations: to provide information on your child’s eye, hearing, dental,
speech/language, OT/PT, developmental and psychiatric tests and the results of those
tests, including who gave the test.
Family/Social Information: to provide information on family members who live with or
care for your child, services for your child and family in the community and other
information that would be helpful for medical providers to know about your family.
Information for Genetic Family Tree: if your child’s illness or disability is genetic, this
form provides a way to track genetic conditions within the family. This form also allows
you to compile the information you need to draw your child’s own genetic family tree.
Suggested Information to Include
-- Immunization Records provided by pediatrician / PCP: attach a copy of your
child’s most recent immunization record from his or her physician.
-- Growth Charts
-- Copies of Genetic Testing
-- Copies of Genetic Family Tree (if available)
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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MILESTONES
Some of the following firsts may be delayed or may never be achieved in a child with a chronic condition or
disability. If you have any questions or concerns, discuss them with your child’s physician. It may help to
write your questions or concerns down before your child’s visit to the physician.
Firsts Date
Smiles
Laughs out loud
Holds head up
Babbles
Rolls over
Sits alone
Walks alone
First tooth
First word
Puts words together
Drinks from a glass or cup
Eats solid food with fingers
Uses a spoon
Indicates needs to use toilet
Toilet trained - bladder
Toilet trained - bowel
Dresses self
Washes self
Other firsts:
________________________
________________________
________________________
________________________
Special talents or skills: _____________________________
________________________________________________
________________________________________________
________________________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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CONCERNS ABOUT MY CHILD’S DEVELOPMENT
Please list any questions or concerns you may have about how your child is growing or developing. Use these notes to
discuss your concerns or questions with your child’s physician.
EXAMPLES:
• Height or weight
• Large muscles: for walking, running, throwing
• Small muscles: for using crayons, markers, or picking up small objects
• Sight or hearing
• Communication: how your child lets you know what he or she wants; talking,
listening, and understanding what you say
• Social skills: how your child gets along with other children or adults
• Learning: including attention span and school work
• Activity level: overactive or underactive
• Feeding
• Sleeping
• Other health concerns/questions for the doctor
CONCERN: DATE NOTICED:
© Junior League Family Resource Center 2005

Eye Exams
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CHILD’S NAME: DATE OF BIRTH:
EVALUATIONS
This form will help you keep a record of the results of eye and hearing exams, as well as any speech, language, and psychiatric tests your child may take.
Date Doctor Results
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
Hearing Exams
Date Doctor Results
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
Dental Exams
Date Doctor Results
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
OT/PT Exams
Date Doctor Results
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
_________________ __________________________________ __________________________________________________
© Junior League Family Resource Center 2005

Speech/Language Tests
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CHILD’S NAME: DATE OF BIRTH:
EVALUATIONS (Continued)
Date Test Administered Given By Results
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
Child Development Tests
Date Test Administered Given By Results
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
Psychiatric Tests
Date Test Administered Given By Results
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
Other Tests and Exams
Date Test Administered Given By Results
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
_________________ _______________________ ___________________ ______________________________________
© Junior League Family Resource Center 2005

At home:
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CHILD’S NAME: DATE OF BIRTH:
FAMILY / SOCIAL INFORMATION
Who lives in the same house or apartment with your child? Please list their ages and relationship to your
child. Include adults and other children.
Name Age Relationship to child Name Age Relationship to child
Who has legal custody of your child?
Name: ________________________________________ Relationship to child:
Who is the main person that takes care of your child during the day?
Name: ________________________________________ Relationship to child:
Who is the main person that takes care of your child during the evening?
Name: ________________________________________ Relationship to child:
Which recent changes or stressors in your family’s home, school, job, etc., might affect your child’s medical
care or be helpful for medical staff to know about?
_______ Change in financial situation
_______ Change in work responsibilities
_______ Child starting at a new school or program
_______ Death of family member
_______ Divorce / separation / marital problems
_______ Move to a new residence
_______ New family members (e. g. new baby or
foster child, new spouse)
In the Community:
Please check any of the following social services your family is receiving:
_______ WIC
_______ Home-based early intervention services
_______ HUG nurses
_______ Other (please describe):
_______________________________________
How do you usually get to the medical care facilities you use?
Family car
Rely on friend or neighbor
Rely on relative
Bus / public transportation
_______ Parent beginning or leaving a job
_______ Pregnancy or causing a pregnancy
_______ Trouble at school_______
Other (please describe): _______________________
_______ Home Health
_______ CSS (Children’s Special Services)
_______ RIP (Regional Intervention Program)
_______ Social Worker
Taxi
TennCare transportation
No reliable transportation
How do you most like to learn about health care information?
_______ Videos _______ Talking to your child’s doctor or therapist
_______ Books _______ Talking to other parents
_______ Pamphlets _______ Other (please describe): _____________________________
_______ Internet
© Junior League Family Resource Center 2005

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CHILD’S NAME: DATE OF BIRTH:
INFORMATION FOR GENETIC FAMILY TREE
Include your child’s siblings and parents, as well as aunts and uncles, nieces and nephews, grandparents, and cousins.
The medical conditions column should include any instances of cancer, heart disease, diabetes, asthma, mental illness, high blood pressure, stroke, kidney disease, alcoholism, vision
or hearing loss, learning problems, and mental retardation. The birth defects column should include instances of spina bifida, cleft lip, heart defects, and the like.
RELATIVE’S
NAME
RELATIONSHIP
BIRTH
DATE
DEATH DATE
(IF APPLIES)
MEDICAL CONDITION(S)
AGE OF
ONSET
© Junior League Family Resource Center 2005
BIRTH
DEFECT(S)
ETHNIC
ORIGIN
JOB

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SUGGESTED INFORMATION TO INCLUDE
� Immunization Records provided by pediatrician/PCP
� Growth Charts
� Copies of Genetic Test Results
� Copies of Genetic Family Tree
© Junior League Family Resource Center 2005

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Daily Routine
• Introduction to Daily Routine Section 25
• Forms
� Important People in My Child’s Life 26
� Special Care and Therapy Routines 27
� Special Equipment Information and Inventory 28-30
� Mealtime Routine 31
� Personal Care 32
� Play Time / Study Time 33
� Bedtime Routine 34
� Transportation 35
© Junior League Family Resource Center 2005

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INTRODUCTION TO DAILY ROUTINE
This section contains information about your child’s routines. It includes:
Important People in My Child’s Life: to provide information on family members, friends,
and pets that are important to your child and the nicknames your child gives to these
people or pets.
Special Care Routines: to describe special routines (suctioning, skin care, therapies,
postural drainage, etc.) and times for these routines.
Special Equipment: to provide instructions and pictures or illustrations of how the
equipment works so that others will learn how to use it and what to do if it breaks down.
Mealtime Routine: provides information on your child’s eating times, food allergies,
favorite foods, and feeding equipment.
Personal Care: provides information on location of your child’s clothing and instructions
for bathing, dressing, toileting of your child, as well as other routines.
Play Time / Study Time: provides information on your child’s favorite activities, toys,
music, and books and on TV, computer, and homework rules.
Bedtime Routine: provides information on your child’s physical care and rituals at
bedtime.
Transportation: describes what your child needs for traveling, seating instructions, and
specific instructions for field trips in programs / schools.
You may want to provide photos of your child to indicate such things as your child’s
seating position in the car or for feedings or any other photos which might help others
learn about your child’s routines.
If your child is of school age, a lot of the information contained in this section will be
helpful to school or program personnel. For example, knowledge of food preferences,
best ways of dealing with equipment, and sitting positions may help school personnel
better assist your child.
Information on daily medications and therapy routines may be found in the Emergency
Health and Information and Health and Development sections of the notebook.
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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IMPORTANT PEOPLE IN MY CHILD’S LIFE
Family Members:
Relationship Name
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
Friends:
Relationship Name
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
Pets:
Type of Animal Name
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
____________________________ _____________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
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SPECIALCARE AND THERAPY ROUTINES
Describe any special routines (suctioning, skin care, therapies, postural drainage) and times for these routines.
Routine Description When Performed
© Junior League Family Resource Center 2005

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SPECIAL EQUIPMENT INVENTORY
This section may be used to record information about your child’s special equipment.
You may want to provide instructions and pictures or illustrations of how the equipment
works so that others will learn how to use it and what to do if it breaks down.
Such equipment may include:
Bili blanket
Braces
Car seats
Casts
Catheters
Communication devices: typewriters, language board, computers
Feeding tubes (NG, gastrostomy, mic-key, peg tube)
Feeding pumps
Monitors
Oxygen
Special seating
Splints
Strollers
Toileting
Tracheotomy tubes
Ventilators (e.g. C-Pap Machine)
Wheelchairs
© Junior League Family Resource Center 2005

1. Equipment:
Who provides (agency, etc):
Condition of equipment:
3. Equipment:
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SPECIAL EQUIPMENT INFORMATION
Purchased Rented
Any unusual things you must do (e.g., wiggle tray, etc.):
Procedure to follow if it breaks down or in the case of an emergency:
Who fixes it: Phone Number:
2. Equipment:
Who provides (agency, etc):
Condition of equipment:
Purchased Rented
Any unusual things you must do (e.g., wiggle tray, etc.):
Procedure to follow if it breaks down or in the case of an emergency:
Who fixes it: Phone Number:
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
Who provides (agency, etc):
Condition of equipment:
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Purchased Rented
Any unusual things you must do (e.g., wiggle tray, etc.):
Procedure to follow if it breaks down or in the case of an emergency:
Who fixes it: Phone Number:
4. Equipment:
Who provides (agency, etc):
Condition of equipment:
Purchased Rented
Any unusual things you must do (e.g., wiggle tray, etc.):
Procedure to follow if it breaks down or in the case of an emergency:
Who fixes it: Phone Number:
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
31
MEALTIME ROUTINE
Usual eating times: ____________________________________________________
Usual length of time to eat: _____________________________________________
Food allergies: Foods to avoid:
_________________________________ ________________________________
_________________________________ ________________________________
_________________________________ ________________________________
_________________________________ ________________________________
_________________________________ ________________________________
_________________________________ ________________________________
Favorite foods / food dislikes: ___________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________
Feeding equipment / utensils used / positioning: ___________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________
Feeding tips: __________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
32
PERSONAL CARE
Location of clothing: ___________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
Instructions for bathing (times, comments): ________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
Instructions for dressing: _______________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
Instructions for toileting (bladder, bowel, times): ___________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
Other routines: ________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
33
PLAY TIME / STUDY TIME
Favorite activities: _____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
Favorite toys / music / books: ___________________________________________
_____________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
Homework rules: ______________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
TV rules: _____________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_________________________________________________________________
Computer rules: _______________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
34
BEDTIME ROUTINE
Usual time your child goes to bed: ________________________________________
Comments: ___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Physical care (bathing, brushing teeth, giving medication, extra padding and diapers,
etc.): _________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
_______________________________________________________________
Bedtime rituals (songs, books, prayer, positioning, use of pillows, sheets and blankets,
favorite toys, use of night light, etc.): ________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________
Does your child sleep through the night? ________
If not, what helps him or her go back to sleep?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
35
TRANSPORTATION
Necessities for traveling (e.g. special equipment): ____________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Seating instructions: ___________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Instructions for field trips at program / school: _____________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
© Junior League Family Resource Center 2005

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Education / School Records
• Introduction to Education Schools Section 37
• Forms 38-39
-- Schools Attended
-- School Log 40
-- Important Program / School Contacts 41
-- Other Information Related to My Child’s Medical 42
Condition to be Shared with Program/School
• Suggested Information to Include: 43
-- TEIS Evaluations and ISPs
-- Copy of IEPs
-- Report Cards
-- School Evaluations
-- Transition Plans
-- Post-Secondary Information and Plans
© Junior League Family Resource Center 2005

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INTRODUCTION TO EDUCATION / SCHOOL SECTION
This section contains information concerning your child in school settings and other
programs and activities your child may be involved in outside the home. It includes:
Schools Attended: provides information on specific educational programs and
schools attended by your child.
School Log: a form to record episodes or events that happen to your child
while at school.
Important Program / School Contacts: provides a place to record names, telephone
numbers, and addresses of individuals to assist you with information and services for
your child.
Other Information Related to My Child’s Medical Condition to be Shared
with Program / School: provides Program / School with additional
information on your child to help others learn how to better assist your
child.
Suggestions:
-- TEIS Evaluations and ISPs
-- Copy of IEPs
-- Report Cards
-- School Evaluations
-- Transition Plans: copies of meeting notes
-- Post-Secondary / Information
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
38
SCHOOLS ATTENDED
This form will help you keep track of school information on your child each year. Begin with the first program your
child attended and enter the new one each time your child changes schools or grades.
Name of Program / School:
Name of School District:
City: State:
Name of Teacher: Grade or Child’s Age:
Check One: Fall Spring Summer Year:
Other school services (e.g. occupational therapist (OT), physical therapist (PT), remedial reading,
speech, etc.):
Name of Teacher / Therapist: Type of Class / Frequency of Attendance
Reason for leaving program / school:
Name of Program / School:
Name of School District:
City: State:
Name of Teacher: Grade or Child’s Age:
Check One: Fall Spring Summer Year:
Other school services (e.g. occupational therapist (OT), physical therapist (PT), remedial reading,
speech, etc.):
Name of Teacher / Therapist: Type of Class / Frequency of Attendance
Reason for leaving program / school:
Early Intervention Programs, Nursery Schools, Preschools,
Day Care, Public Schools, Special Schools
In-home Programs
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
Name of Program / School:
Name of School District:
City: State:
Name of Teacher: Grade or Child’s Age:
Check One: Fall Spring Summer Year:
Other school services (e.g. occupational therapist (OT), physical therapist (PT), remedial reading,
speech, etc.):
39
Name of Teacher / Therapist: Type of Class / Frequency of Attendance
Reason for leaving program / school:
Name of Program / School:
Name of School District:
City: State:
Name of Teacher: Grade or Child’s Age:
Check One: Fall Spring Summer Year:
Other school services (e.g. occupational therapist (OT), physical therapist (PT), remedial reading,
speech, etc.):
Name of Teacher / Therapist: Type of Class / Frequency of Attendance
Reason for leaving program / school:
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
40
SCHOOL LOG
You can use this sheet to keep a record of episodes or events
that happen while your child is at school.
DATE / TIME EPISODE / EVENT
© Junior League Family Resource Center 2005

Doctor
Nurse
Teacher
CHILD’S NAME: DATE OF BIRTH:
Principal
41
IMPORTANT PROGRAM / SCHOOL CONTACTS
This sheet gives you the contact information of people who can assist you with obtaining services for your child.
Address
Address
Address
Address
Guidance Counselor
Address
Special Education Director
Address
Director of School Services
Address
Homebound Coordinator
Hospital
Address
Address
School Superintendent
Address
Right to Education Consultant
Address
Area Education Consultant
Address
Asst. Commissioner of Special Ed.
Address
TN Special Education Services
Address
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
Name Telephone Number
© Junior League Family Resource Center 2005

CHILD’S NAME: DATE OF BIRTH:
42
OTHER INFORMATION RELATED TO MY CHILD’S MEDICAL
CONDITION TO BE SHARED WITH PROGRAM / SCHOOL
The school has the authority to act only on physician’s orders for your child. Additional information may
be helpful to school personnel working with your child so that they may learn how best to assist your
child. For example, you might share information about food preferences, best ways of dealing with
equipment, sitting positions and recommended occupational or physical therapy / exercises with your
child.
© Junior League Family Resource Center 2005

� TEIS Evaluations and ISPs
� Copy of IEPs
� Report Cards
� School Evaluations
� Transitions Plans
43
SUGGESTED INFORMATION TO INCLUDE
� Post-Secondary Information and Plans
© Junior League Family Resource Center 2005

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Resources / Optional Forms
• Introduction to Resources / Optional Forms Section 45
• Suggestions and Information Related to Programs 46-47
and Schools
• Tennessee State Department of Education 48-54
2008 Special Education Manual
Education Resources
• Additional Health and Education Resources from 55
Tennessee Disability Pathfinder
• School Forms
-- Reviewing & Collecting My Child’s Student Records 56
-- TN Dept. of Education Medication Request Form 57
-- TN Dept. of Education Administrative Complaint Form 58
-- TN Dept. of Education Due Process Hearing Request 59
Form
.
© Junior League Family Resource Center 2005

INTRODUCTION TO RESOURCES / OPTIONAL FORMS SECTION
45
This section of the notebook contains additional resources you may find helpful either in caring for your
child or in using this notebook. It includes:
Suggestions and Information Related to Programs and Schools: Explains law
(FERPA) that protects privacy, provides tips for communicating with school personnel,
and information about your child’s rights.
Tennessee State Department of Education 2008 Special Education Manual
Education Resources: Contact information for Tennessee Department of Education
staff, regional resource service centers, state special schools, special education
advisory councils, community resources related to special education, DCS, DHS, TEIS,
vocational rehab state wide centers, national special education offices and sources of
information about IDEA.
Additional Health and Education Resources from Tennessee Disability
Pathfinder: Additional community resources for advocacy and educational support.
Reviewing and Correcting My Child’s Student Records: provides a record of steps
to be taken to review and correct your child’s school records.
Special Education Mediation Request: if you have a conflict with school personnel
regarding your child’s disability, you may use this form to request a mediation session to
try to resolve the issue.
Special Education Administrative Complaint: if you feel an applicable rule or
regulation related to your child’s disability has been violated, you may use this form to
file an official administrative complaint.
Due Process Hearing Request Form: form provided by the Tennessee Department of
Education to request a due process hearing regarding a problem related to the
identification, evaluation, or educational placement of your child. This form must be
filed along with the Special Education Administrative Complaint form.
© Junior League Family Resource Center 2005

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Suggestions and Information Related to Programs and Schools:
Confidentiality: The federal law FERPA (Family Education Rights and Privacy Act)
protects your privacy when a school or agency collects information about your child and
family. Examples of the kinds of information protected are:
information about your child’s condition or disability
individual assessment or evaluation tests of your child
information about your family
copy of your child’s IEP (Individualized Education Plan)
copy of your family’s IFSP (Individualized Family Service Plan)
This information is only available to certain individuals. The school or agency has a list
of individuals who have access to this information. This information may not be shared
with others without parental consent.
If your child is hospitalized for mental illness, it is important to keep informed about how
the hospital and school communicate about your child’s grades and educational
progress at the hospital.
Communication with Program / School Personnel: Encourage communication
among professionals working with your child. There may be information about your
child that you would like to be shared between your physician and your child’s school or
program.
You may give your written permission to share specific information from your physician
to your child’s school or program, or from your child’s school or program to your
physician using a release of information form. Discuss with your physician any
concerns you may have about releasing information that you feel is not necessary for
the school or program to know about your child or family situation.
As a parent or guardian, you have the right to view and obtain copies of your child’s
program and school records. This includes individual assessments or evaluation tests
of your child, specialist reports, Individualized Family Service Plans (IFSPs) and
Individual Education Plans (IEPs).
It is helpful to give copies of health and emergency information to your child’s substitute
teacher, after school personnel, and other school or program personnel your child is in
contact with on a regular basis. To make sure that these individuals understand the
medical needs of your child, it is important to talk directly with each of these individuals
about your child’s medical needs and what should be done in an emergency situation.
Request the school nurse to be present at your child’s IEP Team (M-team) meeting.
Most school districts have their own forms for medical procedures and administration of
medication. Request these forms from your child’s school district.
© Junior League Family Resource Center 2005

Your Child’s Educational Rights: There are laws to protect the educational rights of
children with chronic illnesses and disabilities. These laws include the Individuals with
Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act, and the
Americans with Disabilities Act (ADA).
A link to the Tennessee Department of Education’s publication “Rights of Children with
Disabilities and Parent Responsibilities” may be found at www.finonline.org. This
publication describes the laws and regulations involved in special education within the
state of Tennessee.
Medical Emergencies at Your Child’s Program/School: It is important that everyone
involved in the care of your child know what the plan of emergency care is for your child.
The school will ask you to complete their form with emergency contacts in the event you
are not available during a medical emergency involving your child.
The First Responders Program at your child’s school requires that school personnel be
certified to administer CPR and to administer first aid. Ask school personnel who these
First Responders are at your school.
To ensure that the emergency personnel have access to important medical information
about your child, you may want to share selected information from the Emergency
Health Information Section of this notebook. If you want to keep information that your
provide confidential, it may be given to school personnel in a sealed envelope with your
signature written on the seal. Request that school personnel hand this sealed envelope
directly to the emergency personnel when they arrive at the school.
Find out the nearest emergency room to your child’s school or program and the
emergency room your child’s school uses. Discuss with your child’s physician if these
emergency rooms can provide the necessary care for your child.
47
© Junior League Family Resource Center 2005

48
Resources from
Tennessee State Department of Education
2008 Special Education Manual
Complete manual at http://www.state.tn.us/education/speced/seguidebooks.shtml
COMMISSIONER OF EDUCATION
Dr. Tim Webb
Phone: 6157412731
Tim.Webb@state.tn.us
DIVISION OF SPECIAL EDUCATION CONTACTS
CENTRAL OFFICE STAFF
Andrew Johnson Tower, 7 th Floor
710 James Robertson Parkway
Nashville, Tennessee 37243
Local Phone: 6155328228
TollFree
Phone: 18882123162
Fax: 6153529412
ASSISTANT COMMISSIONER OF SPECIAL EDUCATION
JOSEPH FISHER
Phone: 6157413340
Joe.Fisher@state.tn.us
Administrative Assistant
Nan McKerley
Phone: 6157417796
Nan.McKerley@state.tn.us
Assessment
Ann SandersEakes,
Associate Director
Phone: (615) 7417811
Ann.Sanders@state.tn.us
Assessment & Intervention Programs
Kathy Strunk, Director
Phone: (615) 5321659
Kathy.Strunk@state.tn.us
Autism/Behavioral & Low Incidence Services
Linda Copas, Director
Phone: (615) 7417790
Linda.Copas@state.tn.us
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Kay Flowers, Complaints Consultant
Phone: (615) 5326239
Kay.Flowers@state.tn.us
Compliance Monitoring
Cara Alexander, Director
Phone: (615) 532.6240
Cara.L.Alexander@state.tn.us
Data Management
Terry Long, Director
Phone: (615) 5323262
Terry.Long@state.tn.us
Early Childhood Programs
Jamie Kilpatrick, Director
Phone: (615) 7413537
Jamie.Kilpatrick@state.tn.us
Higher Education Services
May Alice Ridley, Director
Phone: (615) 5324982
Mayalice.Ridley@state.tn.us
Legal Services
Bill Wilson, Director
Phone: (615) 7415988
Bill.Wilson@state.tn.us
State Reporting & Professional Development
Steve Sparks, Director
Phone: (615) 7413619
Steve.Sparks@state.tn.us
State/Private/Charter/Juvenile Detention Centers
Calvin Burden, Director
Phone: (615) 7413538
Calvin.Burden@state.tn.us
State Special Schools
Don Thompson, Liaison
Phone: (865) 5945691,
ext. 124
Don.V.Thompson@state.tn.us
© Junior League Family Resource Center 2005

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Teacher Quality & Development
Angie Cannon, Executive Director
Phone: (615) 5326282
Angie.Cannon@state.tn.us
Regional Resource Service Centers
East Tennessee Regional Resource Service Center
Robert Winstead, Coordinator
Robert.Winstead@state.tn.us
2763 Island Home Boulevard
Knoxville, Tennessee 37920
Phone: (865) 5945691
Fax: (865) 5948909
Middle Tennessee Regional Resource Service Center
Bob Blair, Coordinator
Bob.Blair@state.tn.us
1256 Foster Avenue
Hardison Bldg.
Nashville, Tennessee, 37243
Phone: (615) 5323258
Fax: (615) 5323257
West Tennessee Regional Resource Service Center
Larry Greer, Coordinator
Larry.Greer@state.tn.us
100 Berryhill Drive
Jackson, 38301
Phone: (731) 4215074
Fax: (731) 4215077
© Junior League Family Resource Center 2005

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State Special Schools
Tennessee School for the Deaf
Alan Mealka, Superintendent
amealka@tsd.k12tn.us
2763 Island Home Boulevard
Knoxville, Tennessee 37920
Phone: (865) 5792441
Fax: (865) 5792484
www.tsdeaf.org/
Tennessee School for the Blind
Jim Oldham, Superintendent
jim.oldham@tnschoolfortheblind.org
115 Stewarts Ferry Pike
Nashville, Tennessee 37214
Phone: (615) 2317300
Fax: (615) 8719312
www.tnschoolfortheblind.org
West Tennessee School for the Deaf
Barbara Bone, Superintendent
boneb1@k12tn.net
100 Berry Hill Drive
Jackson, Tennessee 38301
Phone: (731) 4235705
Fax: (731) 4236470
www.wtsd.tn.org
Special Education Advisory Council
Advisory Council for the Education of Students with Disabilities
http://www.tennessee.gov/education/speced/advisory.shtml
Jim Topp, Chair
Jimtopp1@bellsouth.net
© Junior League Family Resource Center 2005

52
RELATED
STATE CONTACTS
The ARC of Tennessee
Walter Rogers, Executive Director
151 Athens Way
Nashville, TN 37228
TollFree
Phone: 18008357077
Phone: (615) 2485878
Fax: (615) 2485879
www.thearctn.org
Disability Coalition on Education in Tennessee
www.dcetn.org
DISABILITY LAW AND ADVOCACY, INC.
Diane Lee, Senior Advocate/Intake Coordinator
dianel@dlactn.org
P.O. Box 121257
Nashville, TN 37212
TollFree
Phone: 18003421660
Fax: (901) 4587819
www.dlactn.org
SUPPORT AND TRAINING FOR EXCEPTIONAL PARENTS (STEP)
Jenness Roth, Executive Director
712 Professional Plaza
Greeneville, TN 37745
Information@tnstep.org
www.tnstep.org
TollFree
Phone: 1800280STEP
Voice: (423) 6390125
Fax: (423) 6368217
Text: (423) 6398802
Tennessee Council on Developmental Disabilities
Parkway Towers, Suite 130
404 James Robertson Parkway
Nashville, Tennessee 372430228
Telephone 615.532.6615
TTY 615.741.4562
Fax 615.532.6964
www.tnddc@state.tn.us
© Junior League Family Resource Center 2005

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TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES
Phone: (615) 7419192
www.tennessee.gov/youth
TENNESSEE DEPARTMENT OF HUMAN SERVICES
Area office numbers and addresses available on web:
www.tennessee.gov/humanserv
TENNESSEE DEPARTMENT OF MENTAL HEALTH AND
DEVELOPMENTAL SERVICES
http://www.tennessee.gov/mental/
5 th Floor Cordell Hull Building
425 5 th Avenue North
Nashville, TN 372430675
Phone: (615) 5326500
Fax: (615) 5326514
TENNESSEE EARLY INTERVENTION SERVICES
Toll Free: 18008527157
VOCATIONAL REHABILITATION SERVICES
http://www.tennessee.gov/humanserv/VRServices.html
Citizens Plaza State Office Building
2nd Floor, 400 Deaderick Street
Nashville, TN 372431403
Phone: (615) 3134891
TTY: (615) 3135695
TTY: (Long Distance): 18002701349
Fax: (615) 7416508
© Junior League Family Resource Center 2005

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Statewide Centers
TriState Resource & Advocacy Corporation
5800 Building, 5708 Upton Road, Suite 350
Chattanooga, TN 374115507
Jackson Center for Independent Living
231D
North Parkway
Jackson, TN 38305
Disability Resource Center
900 E. Hill, Suite 120
Knoxville, TN 37915
Center for Independent Living
480 Craighead Avenue, Suite 200
Nashville, TN 37204
Memphis Center for Independent Living
163 North Angelus Street
Memphis, TN 38104
RELATED CONTACTS
Office of Special Education and Rehabilitative Services (OSERS)
U.S. Department of Education
400 Maryland Ave., S.W.
Washington, DC 202027100
Phone: (202) 2457468
IDEA 2004 – THE LAW
http://frwebgate.access.gpo.gov/cgibin/
getdoc.cgi?dbname=108_cong_public_laws&docid=f:publ446.108
IDEA 2004 – FINAL REGULATIONS
http://idea.ed.gov/download/finalregulations.pdf
Office of Civil Rights
Atlanta Federal Center
Atlanta, Georgia 303038909
Voice Phone: (404) 5627886
Fax: (404) 5627881
© Junior League Family Resource Center 2005

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ADDITIONAL EDUCATION AND HEALTH RESOURCES
1. Family Voices of Tennessee
Advocacy Services, (888) 643-7811, www.tndisability.org/familyvoices/
2. National Alliance for the Mentally Ill (NAMI), Nashville
Advocacy Services, Mental Health Services & Information, Support Groups
(615) 259-7591, www.nami-nashville.org
3. Network of Advocates for Promising Practices in Ed (NAPPE)
Advocacy Services, IDEA Information and/or Training, (423) 534-9827
www.estu.edu/idea/nappe
4. Partnership for EdExcellence
Assistive Technology & Equipment, Autism Resources, Behavior Resources
(865) 974-2760, www.utk.edu/~edex
5. The CAN-LEARN Project, Univ. of TN College of Law
Advocacy Services, IDEA Information and/or Training, Legal Counseling
(865) 974-4141
6. TN Children’s Special Services (CSS), Department of Health
Health Care Services, Health Insurance Information, Hispanic/Latinos Information
Resources, (615) 741-0361, health.state.tn.us/MCH/css.htm
7. TN Voices for Children, Middle TN
Advocacy Services, Autism Resources, Behavior Resources, IDEA Information
and/or Training, Learning Disability Resources, Mental Health Services, Newsletter
Available, Respite Care Services, Support Group, (615) 269-7751, www.tnvoices.org
*Resources updated in October, 2008. To receive most current updates visit
www.familypathfinder.org
(800) 614-INFO [4636] / (615) 322-8529
© Junior League Family Resource Center 2005

Child’s Name: ________________________
School: ______________________
Year: ______________________
REVIEWING AND CORRECTING MY CHILD’S STUDENT RECORDS
The Individuals with Disabilities Education ACT (IDEA) gives parents the right to read school reports and records and
to correct school records by having the school amend it, or by placing a statement prepared by parents into the
records. It also gives parents the right to limit access of other people to their child’s school records and to make
available copies of school records to parents.
Inspecting My Child’s Student Records
Written request to look at school records on: day/month/year
Response from school about looking at records: day/month/year
Contacted me by: mail phone e-mail
And stated:
Appointment made with school on: day/month/year
Reviewing My Child’s Student Records
Name of records reviewed:
Name of records withheld by school: Reason given for withholding records:
Request for copy made on: day/month/year
Copies Provided on: day/month/year
Names of school officials handling request: Titles:
Correcting My Child’s Student Records
Requested correction / deletion of information on: day/month/year
Granted request on: day/month/year
Denied on: day/month/year
Request for hearing at school district level: day/month/year
Hearing date: day/month/year
Name and title of hearing officer:
Results of hearing:
Ensuring the Accuracy of My Child’s Student Records
Name of person contacting you from the Department of Education:
Written decision received on: day/month/year
Results of investigation:
56
© Junior League Family Resource Center 2005

57
SPECIAL EDUCATION MEDIATION REQUEST
ATTN: Legal Services
Tennessee Department of Education
Division of Special Education
5th Floor, Andrew Johnson Tower
710 James Robertson Pkwy.
Nashville, TN 37243-0380
FAX: (615) 532-9412
We would like to request special education mediation on behalf of ,
a student in Schools.
Disability:
We understand this request is for mediation only. A due process hearing
has not been requested.
We understand this request is for mediation concurrent with a request for a due
process hearing. A written request for a hearing has been forwarded to the
Superintendent of Schools.
Summary of Issues to be Mediated:
Preferred date(s), time(s), and place for Mediation Conference:
Sincerely,
*Parent Signature *School System Signature
Parent/Guardian School System Administrator
Name Name
Address Address
City City
Zip Code Phone Zip Code Phone
School System
*Not Valid Unless Both Parties Have Signed
© Junior League Family Resource Center 2005

58
SPECIAL EDUCATION ADMINISTRATIVE COMPLAINT
To: ATTN: Legal Services
Tennessee Department of Education
Division of Special Education
5 th Floor, Andrew Johnson Tower
710 James Robertson Parkway
Nashville, Tennessee 37243-0380
FAX: (615) 532-9412
From:
Name
Address
City State Zip Code
Telephone (Home) Telephone (Work)
Child’s Name
Child’s Date of Birth Child’s Disability
I wish to file an administrative complaint on behalf of
at
School, in the
, a student
School System. The specific grounds/reasons for this complaint are as follows:
Please investigate this complaint and notify me of the results. I understand that it may
be necessary to release a copy of any correspondence submitted by me in relation to
this complaint, my name, the name of the child, and the nature of my complaint to local
school system officials in order to resolve these issues.
Signature Date
© Junior League Family Resource Center 2005

DUE PROCESS HEARING REQUEST FORM
TENNESSEE DEPARTMENT OF EDUCATION
DIVISION OF SPECIAL EDUCATION
PARENT INFORMATION (To be completed by parents and returned to the School System for processing)
Name of Child Name of Parent / Guardian
Child / Parent / Guardian Address
City Zip Telephone Number
Attorney for Child / Parent / Guardian
Attorney's Address
City Zip Telephone Number
Complete description of the nature of the problem of the child relating to identification,
evaluation, educational placement (initial or proposed change) or the provision of a free
appropriate public education (FAPE):
A proposed resolution of the problem to the extent known and available to the parents:
NOTE: Failure on the part of the parents and/or attorney representing the child to comply
with this section could cause a reduction in the amount of attorney’s fees if the child is
the prevailing party.
SYSTEM INFORMATION (LEA must complete information and establish two agreed upon hearing dates)
School System System Administrator
School System Address
City Zip Telephone Number
School Attended Disability
Attorney for School System
Attorney's Address
City Zip Telephone Number
Date Request Received by School System Place Hearing to be Held
Two (2) Agreed upon Dates for Hearing to be Held: Open Closed
Mail and/or fax this request along with a copy of the letter from the parent/guardian
and/or attorney to: ATTN: Legal Services, Tennessee Department of Education, Division of
Special Education, 5
59
th Floor, Andrew Johnson Tower, 710 James Robertson Parkway,
Nashville, TN 37243-0380. FAX: (615) 532-9412
© Junior League Family Resource Center 2005

60
Appendices
� Introduction to Appendices Section 61
� Resources
-- Glossary of Terms 62-63
-- Bill of Rights for Parents 64-66
-- Blank Calendar Sheets 67
-- Index of Forms and Contents 68-70
© Junior League Family Resource Center 2005

61
INTRODUCTION TO APPENDICES SECTION
This section of the notebook contains additional resources you may find helpful either in caring for your
child or in using this notebook. It includes:
Glossary of Terms: explains some of the medical terms and acronyms used in the
notebook.
Bill of Rights for Parents: clearly lists the responsibilities of hospital personnel and of
family members when a child is receiving treatment.
Calendars: customizable to any month and year to help you keep track of
appointments, activities, routines, and important dates.
Index of Forms and Content: lists alphabetically all the forms and resources found in
the notebook.
© Junior League Family Resource Center 2005

62
GLOSSARY OF TERMS
Catheter: a tube used for draining fluid from the body or for injecting fluid into the body.
Central Nervous System (CNS): the brain and spinal cord.
Diphtheria: an acute bacterial illness that causes a sore throat and a fever. It sometimes
causes more serious and even fatal complications. It is caused by the bacillus corynebacterium
diptheriae.
DTP (Diphtheria, Tetanus, and Pertussis): a series of injections that provide immunity against
diphtheria, tetanus and pertussis. DTP vaccine is given at the ages of two, four, and six
months. More injections are given at 15 to 18 months of age and before school at the age of
four to six years. See also diphtheria, tetanus, and pertussis.
Family Educational Rights & Privacy Act (FERPA): a federal law that protects the privacy of
a student’s educational records. It gives parents the right to inspect and review all of the
student’s education records maintained by the school. Schools are not required to provide
copies of the records unless it is impossible for parents to inspect the records. Schools may
charge a fee for copies. Parents have the right to request that a school correct records for
inaccurate or misleading statements. If the school decides not to make amends to the record,
the parent has a right to place a statement in the record that comments on the contested
information in the record.
Gastrointestinal (GI): the part of the digestive system that consists of the mouth, esophagus,
stomach, and intestines.
IDEA: see Individuals with Disability Education Act.
IEP: see Individualized Education Plan.
Individuals with Disability Education Act (IDEA): an educational law relating to children with
developmental delays as defined specifically by each state. The law includes mandates to
provide services to children three to five years of age and six to twenty-one years of age.
School-age children must be provided annual individualized education programs (IEPs).
Children from birth through two years of age receiving early intervention service may be
provided individualized family service plans (IFSPs).
Individualized Education Plan (IEP): a written plan for a child with a chronic condition or
disability that describes the goals, short-term instructional objectives, and special educationrelated
services needed for the child. This plan is required for children over the age of three
years.
Multidisciplinary Team (M-team): a committee of individuals from varying disciplines that meet
to plan for a student’s special needs. The meetings are held as part of the process for
addressing special education requirements or for addressing special needs of the student.
Occupational Therapist (OT): a licensed professional who has training to assist individuals
with an injury or disability to learn or improve their fine motor skills, feeding skills, and daily living
skills, as well as provide instruction on adaptation to equipment.
Pertussis: an infectious disease, also called whooping cough that affects mostly infants and
young children. It is caused by a bacterium, bordetella pertussis that is spread from an infected
person to others by coughing out airborne droplets.
© Junior League Family Resource Center 2005

Physical Therapist (PT): a licensed professional who has training to assist individuals with an
injury or disability with learning or improving physical movement and positioning and with the
development of gross motor skills.
Respiratory Therapist (RT): a licensed professional who has training to assist individuals with
impaired lung function or the prevention and treatment of pulmonary complications after
surgery. The therapist treats severe respiratory diseases and cares for the respiratory needs of
individuals who are on ventilators or who are recovering from major operations.
Tetanus: a serious, sometimes fatal disease of the central nervous system, caused by infection
of a wound with spores of bacterium clostridium tetani. A shot is needed every ten years to
immunize against tetanus.
Tracheotomy: an operation performed to make an opening in the trachea (windpipe) for
insertion of a tube to maintain an airway for an individual who is unable to breathe through the
normal air passages. This procedure allows air to go in and out of the lungs.
Varicella: another name for chicken pox.
Ventilator: a life support machine or respirator used to take over respiration in an individual
who lacks or has lost the ability to breathe naturally. The ventilator is an electrical pump
connected to an air supply that works like bellows.
63
© Junior League Family Resource Center 2005

Responsibilities of Hospital Personnel:
64
BILL OF RIGHTS FOR PARENTS
You can make choices whenever possible. Sometimes you can help decide when and where
you get your treatment. In this hospital you and your child have the right to:
Respect and personal dignity
• You and your child will be treated with courtesy and respect.
• We will introduce ourselves. We will explain our role in your child’s care.
• You can help us get to know your child. We can learn from you what is best for your family.
We will take the time to listen.
• The things you tell us in confidence will be kept private.
• We will speak and write respectfully about your child and family.
• We will honor you privacy.
Care that supports you as a family
• You and other family members are welcome in the hospital, because you and your family
are the most important people to your child. Being together is important.
Information you can understand
• You have the right to complete information from people helping you care for your child.
• You can ask what is happening to your child and why. Everything will be explained to you
honestly in ways you can understand.
• Someone who speaks your language will help explain things to you.
• You have the right to ask questions about anything that is unclear to you.
• You can ask to have someone from your family or another support person with you when
people in the hospital are explaining things to you.
• You have the right to know about your child’s condition and treatment plan. You have the
right to see and review your child’s medical records with health care personnel.
• You have the right to detailed information about your child’s hospital bill.
• You have the right to know the policies, procedures, and routines of the hospital.
• You have the right to know the hospital’s process for taking care of your concerns or
complaints.
© Junior League Family Resource Center 2005

QUALITY HEALTH CARE
• There are so many people who take care of your child in the hospital. You have the right to
know who they are and what they do.
• You can expect to have your child cared for by doctors, nurses, and others who know how
to care for children and youth.
• You are an important member of your child’s health care team. You know your child best.
The information you have is important. Please share the information with us so that
together we can plan what is best for your child.
• Before your child leaves the hospital, we will teach you about the care your child will need.
We will tell you about people and places in your community that can help you.
EMOTIONAL SUPPORT
• When your child is in the hospital, you might feel afraid, angry, guilty, sad, lonely, or tired.
You can talk with health professionals about your feelings, questions, problems, or
concerns. They will listen to you and respect your feelings.
• If you want help, you can decide whom you want to help you.
• We can help you meet other families who have had experiences like yours.
CARE THAT RESPECTS YOUR CHILD’S GROWTH AND DEVELOPMENT
We will consider all your child’s interests and needs, not just those related to illness or disability.
Your child will be cared for by people who understand the needs and concerns of children and
teenagers.
We will try to keep your child’s schedule and activities as normal as possible. This includes
uninterrupted sleep, quiet times, play times, school, and the comfort of family and friends.
MAKE DECISIONS ABOUT YOUR CHILD’S CARE
• You have the right to information you need to make decisions about your child’s care.
• We will explain all options so that you can understand the risks and know what the choices
are for your child’s care.
• We will work in partnership with you to make decisions about your child’s care.
• You may refuse treatments as permitted by law.
• You may change your mind about care for your child even if you have already given
permission.
• You may ask to change hospitals.
• If it is necessary to transfer your child to another hospital, we will make every effort not to
move your child until you have been told why.
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© Junior League Family Resource Center 2005

Responsibilities of the Family, in this hospital, you have the responsibility to:
Provide information
You have important information about your child’s health. We need to know about symptoms,
treatments, medicines, and other illnesses.
You should tell us what you want for your child.
It is important that you tell us how you want to take part in your child’s care.
You should tell us if you don’t understand something about your child’s care.
If you are not satisfied with your child’s care, please tell us.
Provide appropriate care
You and the other members of the health care team work together to plan your child’s care.
You are responsible for doing the things you agreed to do in this plan of care. If you cannot
follow the plan, tell us.
Meet financial obligations
You should help to make sure that your child’s hospital bill is paid as promptly as possible.
Respect and consider the rights of others.
Your family is expected to respect the rights of other children, families, and hospital personnel.
NOTE: Reprinted from A Pediatric Bill (pp. 1-12 by the Association for the Care of Children’s
Health, 1991, Bethesda, MD. Copyright 1991 by ACCH).
State of Tennessee
Emergency medical services
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© Junior League Family Resource Center 2005

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Month: ______________________________________________ Year: _______________________
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
© Junior League Family Resource Center 2005

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INDEX OF FORMS
A Page
Administrative Complaint – TN Dept. of Education 58
Allergies 11
Allergies, Latex 12
Appendices Section, Introduction to 60-61
B
Baseline Data 9
Bedtime Routine 34
Bill of Rights for Parents 64-66
C
Calendars 67
Concerns About My Child’s Development 18
Contents & Introductions
to Appendices Section 60-61
to Daily Routine Section 24-25
to Education / School Records 36-37
to Emergency Health Information 4-5
to Family Information Notebook 1-3
to Health and Development Section 15-16
to Resources / Optional Forms 44-45
Correcting My Child’s Student Records 56
D
Daily Routine Section, Introduction 24-25
Development, Concerns About 18
Developmental Milestones 17
Due Process Hearing Request Form – TN Dept. of Education 59
E
Education and Health Resources, Additional 55
Education/School Records Section, Introduction 36-37
Emergency Contact Information 6
Emergency Info Section, Introduction 4-5
Evaluations 19-20
© Junior League Family Resource Center 2005

F Page
Family Resource Center Contact Information 2
Family / Social Information 21
G
Genetic Family Tree, Information for 22
Glossary of Terms 62-63
H
Health and Development Section, Introduction 15-16
I
Important Contacts for Program/School 41
Important People in My Child’s Life 26
J
Junior League Family Resource Center Contact Information 2
L
Latex Allergies 12
M
Mealtime Routine 31
Medical Information 7
Medical Power of Attorney 13
Medications 8
Medication Request Form – TN Dept. of Education 57
Milestones of Development 17
O
Other Information to be Shared with Program / School 42
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P Page
Personal Care 32
Play Time / Study Time 33
R
Resources from Tennessee State Department of Education 48-54
2008 Special Education Manual
Resources / Optional Forms Section, Introduction 44-45
Reviewing and Correcting My Child’s Student Records 56
S
Schools Attended 38-39
School Log 40
Special Care and Therapy Routines 27
Special Education Administrative Complaint 58
Special Education Due Process Hearing Request 59
Special Education Mediation Request 57
Special Education Review and Correct Records 56
Special Equipment Inventory and Information 28-30
Surgery or Procedure Records 10
Suggested Information to Include
• For Emergency Health Information 14
• For Health and Development 23
• For Education/School Records 43
Suggestions and Information Related to Programs and Schools 46-47
T
Table of Contents 3
Tennessee State Department of Education - Resources
Therapy Routines 27
Transportation 35
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© Junior League Family Resource Center 2005