Section 504 Plan for: _______________
(Draft)
Student’s Name:
School:
Grade:
Birth Date:
School Year:
Teacher:
BACKGROUND
(short summary of surgeries and Early Intervention services.)
OBJECTIVES/GOALS OF THIS PLAN
The student has complex congenital heart defects that require the accommodations and modifications set
out in this plan to ensure that the student has the same opportunities and conditions for learning and
academic testing as classmates, with minimal disruption of the student’s regular school schedule and with
minimal time away from the classroom.
REFERENCES
Children with complex congenital heart defects often have physical deficits which affect their cardiac and
respiratory systems. In some cases, they are also affected neurologically which can affect language
development, behavior, and learning abilities.
Wernovsky G. The Emerging Recognition of School and Behavior Problems in Children with
Congenital Heart Defects, The Congenital Heart Information Network. 2005 Sept;27.
http://tchin.org/resource_room/CHDSchool.htm
Brown MD, Wernovsky G, Mussatto KA, Berger S. Long-term and developmental outcomes of
children with complex congenital heart disease. Clin Perinatol. 2005 Dec;32(4):1043-57, xi.
ACADEMIC-RELATED ACCOMMODATIONS
1. HEALTH CARE SUPERVISION
1.1. Any staff member who has primary care for the student at any time during school hours,
extracurricular activities, or during field trips, needs to be aware of student’s condition and
symptoms which may indicate a health problem. Primary care means that the staff member is in
charge of a class or activity in which the student participates.
2. EXERCISE AND PHYSICAL ACTIVITY
2.1 The student should participate in physical education classes and team sports with the following
exceptions:
a.
no contact sports
b.
no long-distance running
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2.2 Physical education instructors and sports coaches must be able to recognize lack of stamina issues
pertaining to the heart condition and act accordingly. Per cardiologist’s instructions, student must:
a.
be allowed to “self limit” or rest if tired
b.
rest in the shade or air conditioning if overheated
c.
get warm if exposed to cold and visibly turning blue
d.
have access to water at all times in order to stay hydrated
3.
WATER AND BATHROOM ACCESS
3.1 The student shall be permitted to have immediate access to water by keeping a water bottle in the
student’s possession and at the student’s desk, and by permitting the student to use the drinking
fountain without restriction.
3.2 The student shall be permitted to use the bathroom without restriction.
4. FIELD TRIPS AND EXTRACURRICULAR ACTIVITIES
4.1 The student will be permitted to participate in all field trips and extracurricular activities (such as
sports, clubs, and enrichment programs) without restriction and with all of the accommodations
and modifications set out in this Plan.
4.2 The student’s parent/guardian will not be required to accompany the student on field trips or any
other school activity but will have the right to accompany the student on any field trips or other
activity.
5. TESTS AND CLASSROOM WORK
5.1 If the student needs to take breaks to use the water fountain or bathroom, get cooled off, or
warmed up, the student will be given extra time to finish the test without penalty.
5.2 The student shall not be penalized for absences required for medical appointments and/or for
illness.
6. DAILY INSTRUCTIONS
6.1 The school nurse or teacher will notify parent/guardian 3 days in advance when there will be a
change in planned activities such as exercise, playground time, and field trips so that parent can
plan accordingly.
6.2 Each substitute teacher and substitute school nurse will be provided with written instructions
regarding the student’s heart condition.
7. EMERGENCY EVACUATION AND SHELTER-IN-PLACE
7.1 In the event of emergency evacuation or shelter-in-place situation, the student’s 504 Plan will
remain in full force and effect.
8. PARENTAL NOTIFICATION
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8.1 NOTIFY PARENTS/GUARDIANS IMMEDIATELY IN THE FOLLOWING SITUATIONS:
 Student exhibits extreme tiredness, lethargy.
 Any loss of consciousness.
 Child looking “blue” (especially lips, fingernails) and not returning to normal when warmed up.
 Child overheated and not cooling off in a reasonable time period.
 Any injury – especially any blows to the chest, or any cuts especially in the mouth (since some
cuts will require antibiotic prophylaxis).
 Potential exposure to any respiratory illnesses such as pneumonia, bronchitis, and other illnesses
such as fevers, strep throat, and chicken pox.
8.2 EMERGENCY CONTACT INSTRUCTIONS
1.
2.
3.
4.
Call the student’s home. If unable to reach parent/guardian:
Call the student’s parent/guardian’s cell or work phone. If unable to reach parent/guardian:
Repeat same steps with student’s other parent/guardian, if applicable. If unsuccessful:
Call the other emergency contacts listed below.
Physicians:
Pediatrician – Phone
Cardiologist - Phone
Contacts: Name
Relation
Home
Cell
This Plan shall be reviewed and amended on (date): ________________________________
Approved and received:
____________________________________________________________
________________
Parent/Guardian
Date
____________________________________________________________
________________
School Representative and Title
Date
____________________________________________________________
________________
School Representative and Title
Date
____________________________________________________________
________________
School Representative and Title
Date
*****
Updated 09/06/2006
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