EMERGENCY 504 FOR SPRING 2014 TESTING
LOUISIANA STATE DEPARTMENT OF EDUCATION
SECTION 504 STANDARDIZED ASSESSMENT DATA VALIDATION FORM for K-12
STUDENTS WITH DISABILITIES (Section 504 Eligible)
Instructions: This form must be completed and submitted to LDE after determining that students are eligible for Section 504 services
and before providing standardized testing accommodations to students who routinely receive Section 504 accommodations. LEA
Section 504 Coordinators must ensure that a copy of this form accompanies the original Individual Accommodation Plan for students
with disabilities (Section 504 Eligible). Information obtained from this form will be used for gathering statistical data for research-based
initiatives, data validation of students receiving accommodations for standardized statewide assessment, training and/or technical
assistance purposes.
School District:_Jefferson_ School:____________________ School Code:_______Principal:________________________
SBLC/504 Chairperson:_____________________ District Section 504 Coordinator:_ NA
Date:_______
Total # of 504 Students Receiving Test Accommodations in School:___NA____ Total # of 504 students on site:__NA___
Student’s Name
Last 4 digits
of student’s
SS #
Grade
Qualifying
Disability
Standardized
Assessment
Accommodations Needed for Assessment
(Codes may be used) ex. #68-Braille
School District:_Jefferson_______
Student’s Name
Last 4 Digits of
student’s SS#
School:_________________________
Grade
Qualifying
Disability
Standardized
Assessment
Page ___ of
Accommodations Needed for Assessment