Pasco County Schools
Rev 06/2015
Annual 504 Protections Only Review / Multiple Teachers
, a student in your class, is eligible for Section 504 and receives 504
Protections Only (no accommodation plan):
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations due
to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations
due to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations due
to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Student Name:
Annual 504 Accommodation Plan Review/Multiple Teachers
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations due
to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations
due to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Please Complete the Following: (check one statement below)
I acknowledge that this student is Protected under Section 504. This student is afforded:
Manifestation Determination Hearing, Procedural Safeguards, Periodic Reevaluation (if the
need for accommodations arises), and Non-Discrimination Protections.
I would like to discuss some concerns and/or possible need to develop accommodations
due to the student’s impairment. I have data to support my concerns.
Comments: _________________________________________________________________
____________________________________________________________________________
Teacher Signature ____________________________________ Date _____________
Please Return to: ________________________________________ By:____________
(Name of Person to Return To)
(Date)