Remote Service Delivery Informed Consent

As stated in the CAIU’s Continuity of Education Plan (CoE) and reflected in the PWN/NOREP you will receive, the CAIU is offering the opportunity for your child to access educational experiences during the period of building closure due to the COVID-19 pandemic. Given the sensitive nature of information contained in special education records and the prohibition against in-person service delivery, we would like to document your consent for remote service delivery. Please read this document carefully and communicate any questions you have to your child’s case manager.

I _________________________________________, (name of parent or guardian) hereby consent to the participation of ________________________________ (name of student) in remote service delivery with _______________________________ (name(s) of provider(s)) as part of my child’s educational services through the school district’s CoE.  I understand that remote service delivery is the practice of delivering some level of service via technology assisted media or other electronic means between a teacher or service provider and a student (and, if applicable, the student’s guardian) who are in two different locations.

I understand, and hereby agree to the following with respect to remote service delivery:

  1.  I have the right to withdraw consent for remote delivery at any time by providing written notice to my child’s case manager. I understand that remote service delivery is only available to my child a result of the pandemic of 2020 and will not be available upon the re-opening of school buildings.
  2. The provision of remote services does not constitute an amendment to my child’s IEP. I understand that I should use the established procedure for addressing the substance of my child’s IEP, requesting an IEP team meeting, or requesting a modification of my child’s IEP.
  3. Remote service delivery represents the District’s good faith effort to provide educational opportunities based on my child’s unique needs and IEP goals in light of the circumstances caused by the pandemic.  I understand that the special education and related services that are included in my child’s IEP may typically involve hands-on interaction (e.g., physical therapy, occupational therapy, social skills). I understand that remote service delivery does not involve hands-on, in-person service delivery because of the danger of in-person service delivery during the health emergency.
  4. Remote service delivery is being offered to fulfil the District’s obligation to provide CoE to all students and is not being delivered in addition to the special education and related services outlined in my child’s IEP.
  5. There are risks, limitations, and consequences associated with remote service delivery, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies. I understand that I may be asked to support remote service delivery and will ask for assistance or clarification, if necessary, or will decline to provide support if I am unable.
  6. There will be no recording of any of the online sessions by either party.  An exception exists where recording the student serves a legitimate educational purpose as part of remote service delivery. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written consent, except where the disclosure is permitted and/or required by law. I understand that the privacy laws that protect the confidentiality of the personally identifiable information (PII) found in my child’s education records also apply to remote service delivery unless an exception to confidentiality applies (e.g., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).
  7. If I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that remote service delivery services are not appropriate and a higher level of care is required.
  8. During a remote service delivery session, we could encounter technical difficulties resulting in service interruptions.  If this occurs, end and restart the session.  If we are unable to reconnect within ten minutes, please collaborate with the teacher or service provider to reach an appropriate solution.
  9. My school based provider may need to contact my child’s emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols

The District needs to know your location in case of an emergency.  If you and your child are not located at the address provided below, you agree to inform the teacher or service provider of the address where you are located at the beginning of the session. 

In case of an emergency, my location is:_____________________________________________

and my emergency contact person’s name, address, phone:______________________________


I have read the information provided above and discussed it with my child’s case worker, teacher, or service provider.  I understand the information contained in this form and all of my questions have been answered to my satisfaction.


_________________________________________________                           ___________________

Signature of parent/legal guardian                                                            Date


_________________________________________________                           ___________________

Signature of case worker, teacher, or service provider                                 Date