McDowell County Schools
Section 504 Student Accommodation Plan
School____________________________________
Student___________________________
Start Date________________
Grade_____________
DOB_____________________ Age______________
End Date_____________________
Power School Number_____________________
Parent Name_________________________________________________
Phone________________
Parent Name_________________________________________________
Phone________________
Student is eligible for 504 Plan: Yes_______ No______
If no, indicate reason____________________________________________________________
Nature of physical or mental impairment, including the impact of the
disability on a major life activity, as defined under Section 504/ADA:
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What is the impact of the disability on the student’s academic and nonacademic performance? (Attach more sheets if necessary)
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Accommodations in the classroom, for standardized testing,and/or other
school settings. Include academic/non-academic accommodations. Note:
Testing accommodations should be evident in classroom accommodations.
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Are there mitigating factors in place that positively impact the student’s
performance in the school and decrease the need for accommodations?
Yes____________ No ______________
If yes, indicate how these measures will be implemented, monitored, and
maintained.
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If the above mitigating factors are discontinued or become ineffective, the
following steps will be taken to accommodate the student’s disability and/or
develop a new plan:
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Signatures of Section 504 Committee Members:
Parent/Guardian___________________________________________________________________________
Teacher______________________________________________________________________________________
Teacher______________________________________________________________________________________
Teacher______________________________________________________________________________________
School 504 Coordinator___________________________________________________________________
Administrator_______________________________________________________________________________
I have received a copy of this plan and have received notification of parental
rights under Section 504.
Parent/Guardian Signature: __________________________________________________________
Copies: Parent(s), Teacher(s), 504 Folder, Central Office District Level 504
Coordinator, Test Coordinator at the school level, School Data Manager for
entry into Power School