New Hanover County Schools
How To Complete Section 504 Data Collection Tool:
Reason Section 504 Data Collection Tool is Being Completed:
Initial Is this the first time data is being collected to determine if student meets criteria for a Section 504 Plan?
Review Is this a review of a student who currently has a Section 504 Plan to determine if student continues to meet requirements for a plan?
Exit Is this data collected being used to document that the student no longer meets requirements for an
Intervention Accommodation Plan?
Name
Student ID
Date of Birth
Completed By
(Role)
Student Name Date
Student Number Assigned by PowerSchool Grade
Date Data Collection Tool Being Completed
Current Academic Grade
Student Date of Birth School Current School Attending
Name and Role on Section 504 Team of People Completing Data Collection Tool (i.e., Charlie Brown –
Classroom Teacher; Suzy Q – Section 504 Coordinator)
List student strengths and areas of need to include academic, behavioral and social skills:
Student Strengths: Areas of Need:




Background History:
 Top Row: Current Academic School Year
 Second Row: Previous Academic School Year
Grade & Attendance: Absent / Tardy
School Attended

Discipline / Behavioral Information:
 Discipline Referrals (#)
 In-School Suspensions (#)
Out-of-School Suspensions (#)
Academic Grades:
 Indicate Quarters or Semesters or Final Average
 Indicate if Work Completed was Grade Level
Material or Modified
 How many credits has the student earned at the high school level?




Grade in School & Number of Days Absent / Tardy
School Student Attended
 How many discipline referrals has this student received, if any? What were the reasons for the referrals?
 How many times has the student received In-School

Suspensions and for how many days?
How many times has the student received Out-of-School
Suspensions and for how many days?
 List academic grades (Language Arts, Reading, Math, Science and Social Studies) earned by student and when this information was gathered (i.e., 1
1 st or 2 st quarter, 2 nd Semester; or Final Average) nd quarter, etc.;
 Was the academic grades earned the first time performance of student on grade level material? If no, indicate what level and/or modifications were made for student.
12.2013

New Hanover County Schools
Testing Information:
Benchmark and/or Progress Monitoring Data (DIBELS, mClass, New Hanover County Curriculum Based Probes)
Date (Beginning of Year or Fall Season / Middle of Year or Winter Season / End of Year or Spring Season):
Example:
May 2013 (Spring Season; End of Year Benchmark)
Skill / Probe
Examples:
New Hanover County Curriculum Based Probes:
Phrase Fluency
Quantity Discrimination
DIBELS:
DIBELS Oral Reading Fluency
Formative Assessment Data (Classcape Data)
Student Performance Targeted Goal / Proficient Level
32
15
107
79
23
90
Date (Fall/Winter/Spring)
January 2013 (Winter)
Reading/Math
Reading
Student Performance
36%
Grade Average
42%
District Average
47%
End of Grade Test
Results:
Example:
End of Course
Results:
Grade:
4 th
Date:
Test:
Score:
Reading (Scaled Score & Level):
342 & Level 3
Date:
Test:
Score:
Date:
Test:
Score:
Math (Scaled Score & Level):
338 & Level 2
Date:
Test:
Score:
Has the student made peers?  No  Yes routine use of instructional accommodations for assignments and assessments when compared to
What has been implemented and what were the results?
Accommodations and modifications include adaptations to the physical arrangement of the classroom, as well as changes to instructional delivery. Such changes can include modifications to lesson presentation, student responses, and evaluation and assessment techniques. Some accommodations and instructional modifications are teacher-oriented (e.g. changes in how the information is presented) and some are focused on changes in how the student engages in and responds to the lesson.
Does the student exhibit frequent behaviors, such as drowsiness, impulsivity, inattentiveness, or aggressiveness, directly associated with an identified physical or mental impairment, and do these behaviors significantly interfere with
school performance?  No  Yes
Describe the behavior What is the behavior that the student is displaying? Define the behavior objectively so
12.2013

New Hanover County Schools
Time(s) of Day Behavior
Observed:
What is the Frequency / Duration
(Length) of these Behaviors: that everyone observing the student would agree on when the student displays the behavior.
Example: Student talks without raising his hand and waiting to be called on.
Example:
During academic classes, student call-outs ~20 times per 45 minute block.
Example:
These behaviors typically occur after half of the academic period has elapsed but on a daily basis.
Does the student exhibit significant difficulty with planning, organization and completion of school-related activities and assignments?  No  Yes
If yes, describe:
Does the student demonstrate the ability to break down tasks into smaller, manageable steps to completion?
Does student take advantage of resources made available to all students so that work is completed in a timely manner?
Does student use time efficiently and prevent distractions from interfering with work completion?
Is the student chronically absent or tardy for reasons related to a diagnosed physical or mental impairment, and are these absences or tardies interfering with school performance?  No  Yes
If yes, describe:
Are there other indicators that this student’s physical or mental impairment substantially limits a major life activity?
 No  Yes
If yes, describe:
The use of mitigating measures can be relevant in determining the need for a Section 504 Accommodation Plan. Are mitigating measures in place?  No  Yes
If yes, describe the measures and the impact of mitigating measures:
12.2013