1 Start 2 Complete Welcome to the Student Case Submission Form for ECHO Idaho's K12 Education Behavioral Health series.Case Study Discussion GuidelinesAs part of our training, we will be engaging in discussions about student case studies. This is a wonderful opportunity to learn from each other, share experiences, and explore solutions collaboratively. Presenter First and Last Name * School Role and/or Credentials * Email * Phone number * City, State * ECHO Idaho offers $100 in compensation for case presentations. Would you like to accept compensation for presenting this case? * Yes (ECHO staff will reach out to you with compensation paperwork that must be completed three weeks prior to your presentation date.) No, I would like to donate my time. Please do not include any identifiable student information, Personally Identifiable Information (PII), or Protected Health Information (PHI) or information protected by The Family Educational Rights and Privacy Act (FERPA). If you have any questions regarding this form, please contact echoidaho@uidaho.edu. * Click here to acknowledge. Student Grade Level PreK K-2 3-5 6-8 9-12 18-21 Program Please indicate if this is a new student case or if this is a follow-up to a previously presented case: New student case Follow-up to a previously presented student case Are you willing to present a follow-up on this student in 3 months? Yes No Maybe Did the advice you received from the ECHO panelists in your initial presentation change the way you approached this student's case? If so, in what ways? If not, why not? What progress has the student made since your initial presentation? Have you and/or the student encountered additional challenges or obstacles? If so, what were they? What help or advice would you like from the ECHO Idaho specialists? Describe the specific challenge or concern with this student: Discuss any interventions that have been tried with this student. If relevant, please describe policy or systems level information that may provide additional context for this case. If relevant, what current medication(s) is this student taking? Please list any known past or current diagnoses for this student. Please list any relevant, non-identifiable background information about the student (e.g., medical/psychological diagnoses, family/social history, etc.). Is this student on an IEP? Yes No List any relevant and non-identifiable accommodations that are stipulated on the student's IEP. Is this student on a 504 Plan? Yes No List any relevant and non-identifiable accommodations that are stipulated on the student's 504 plan. Has an outside evaluation been completed (i.e., Functional Behavior Assessment)? If yes, please summarize the outcome of the assessment. Does the student have a Behavior Intervention Plan (BIP) in place? Yes No Does the student participate in any services outside of the school setting? Yes No What do you hope to achieve with regards to this student? What does the student/family hope this student will achieve? What specific questions do you have for ECHO about this student or situation? Thank you for completing ECHO Idaho's K12 Behavioral Health Case Submission Form. You will receive a copy of your responses in the email you provided and be contacted by ECHO staff about presenting your case in a session or follow-up consultation with a panelist within two business days. FERPA & HIPAAOur discussions must also strictly comply with the Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA). FERPA is a federal law that protects the privacy of student education records. This means that any academic information, such as grades or educational services received, should not be shared without explicit consent from the student or the student's parents if the student is a minor. Meanwhile, HIPAA safeguards patient health information. Under HIPAA rules, it is prohibited to disclose health information that could identify a patient. This includes medical histories, treatment records, or any other health-related information. Discussion Etiquette1. Please use broad terms when discussing a student’s academic performance or health information. 2. Consider using fictitious names or simply refer to the student as "the student." 3. Share information only as relevant to the professional development of the group, always keeping the student's privacy at the forefront. Our goal here is to learn and grow as professionals, not to investigate personal details of our students' lives. Their trust in our services hinges on our commitment to confidentiality and respect for their private information. Thank you for your commitment to upholding these crucial standards. Leave this field blank
