Section 504 Plan
__________________ Community School District
Section 504 Coordinator: ______________________ Date: ________________________
Student’s Name: ______________________________
Date of Birth: _________________
Grade/Class: _________________________________ Age: _________________________
Parent’s Name (s): ____________________________
______________________________
Address: _______________________________ City, State, ZIP: ______________________
For an impairment to be considered as substantial, limitations in the student’s academic and/or behavioral performance must be greater than the academic and/or behavioral performance of his or her nondisabled peers. The team must determine whether a particular impairment substantially limits a major life activity. Simply having a diagnosis of a mental or physical impairment does not, in itself, establish that a student has a disability under Section 504.
Supporting Documentation:
_____ Adaptive and/or achievement tests
_____ Adaptive Behavior
_____ Student File/Reports
_____ Medical Reports/Evaluations
_____ Teacher Recommendation(s)
_____ Report Card & Scholastic Record
_____ Other documentation (specify):
__________________________________
_____ Parent Input
Rational for Section 504:
Step 1:
__________________________________
Identified mental impairment: __________________________ and/or
Identified physical impairment: _________________________
Step 2: Substantial Limitation resulting from the impairment:
(considerable, extensive, significant)
_____ Hearing _____ Performing manual tasks ____Thinking _____ Learning
_____ Speaking _____ Walking ____ Working
_____ Seeing _____ Breathing _____ Caring for one’s self
____ Concentrating _____Organizing _____ Sleeping
____Standing
____Lifting
____Eating
List any medications: __________________________________________________________
1

Step 3: Student’s classroom and school performance validates a degree to which the mental or physical impairment limits the student’s major life activity when compared to other, nondisabled students: [ ] Yes [ ] No
Is the student’s academic performance and/or behavior markedly below that of average, nondisabled peers? [ ] Yes [ ] No
If no, please describe: ______________________________________________
Evaluation materials must demonstrate that the student’s academic and/or behavioral performance is less than that of the average nondisabled student.
Step 4: Areas of Concern and Identified Needs: (indicate yes or no)
_____ The student demonstrated a consistent need for substantially more time to complete homework assignments and in-school assignments than is required by the average nondisabled student. If yes, indicate the types of assignments in which more time is required and the percentage of additional time required for each type.
____ The student consistently requires modified testing to be able to demonstrate knowledge. If yes, indicate the type of subject matter and the types of testing and the modifications required.
_____ The student exhibits significant difficulty in planning, organization, and execution of school-related activities and assignments. If yes, describe:
_____ The student is chronically absent or tardy for reasons related to a diagnosed physical or mental impairment and are absences or tardies interfering with school performance. If yes, indicate the number of absences during the previous school year and in the current school year.
_____ The student has experienced a steady decline in academic performance for which there is no known cause other than the diagnosed physical or mental impairment. If so, describe the extent of this decline.
_____ The student has a medical condition requiring medication administration or other accommodations during the school day. If yes, describe the accommodation, and the frequency of administration during the school day.
Does the impairment impact the student’s education: [ ] Yes [ ] No
Step 5: Is the student disabled under Section 504? [ ] Yes [ ] No
If it has been determined that the above mentioned student is eligible for services under Section 504, then the team should continue to complete this document.
If not, the team may want to consider the development of an intervention plan for the student.
2

The fundamental purpose of Section 504 is to prevent discrimination against students identified as having disabilities under either IDEA or Section 504 by providing qualified students with disabilities educational opportunities commensurate or equal to those provided to nondisabled students.
The obligation to provide services to students with disabilities to “the maximum extent appropriate” with their nondisabled peers is known as serving students in the least restrictive environment (LRE).
Identify accommodations required to meet the needs of the student’s identified disability:
1.
________________________________________________________________________
2.
________________________________________________________________________
3.
________________________________________________________________________
4.
________________________________________________________________________
____ Extended Time
____ Crammer-Abacus
____ Read Aloud
____ Dictation to Scribe
____ Braille/Braille Writer
____ Magnification Device
____ Large Print
____ Computer Adapted
____ 1 Item/Page
____ Marks in Book
____ Assistive Devices
____ Multiple Sessions
____ Interpreter/Transliterator ____ Computer w/Processor ____ Separate Room Testing
____ Other ___________________________________________________________________________________
Plan Type: ____ Initial ____ Reevaluation ____ Continuation
LRE: ____ General Classroom ____ Other: _________________________
I have participated in the development of this plan and have received a copy of the Section
504 Rights Handbook.
Parent Signature: ______________________________________ Date: __________________
____ Annual Review
Initial & Date: ___________ Initial & Date: ____________
Initial & Date: ___________ Initial & Date: ____________
Initial & Date: ___________ Initial & Date: ____________
Initial & Date: ___________ Initial & Date: ____________
Initial & Date: ___________ Initial & Date: ____________
3

Team Signatures
Title Signature and Date
504 Coordinator __________________________________
Agree
Parent(s)/Guardian __________________________________
Administrator __________________________________
Classroom Teacher __________________________________
Classroom Teacher __________________________________
Social Worker __________________________________
Psychologist
Ed Consultant
__________________________________
__________________________________
School Counselor __________________________________
Other Members __________________________________
__________________________________
Disagree
*Explanation of disagreement
is attached.
FOR STUDENT SERVICES TEAM USE
Date of Initial Team Meeting _________________________________
Date of Second Team Meeting ________________________________
Date of Third Team Meeting _________________________________
Date of Parental Notice of Screening Procedures Sent ____________
Date of Initial Section 504 Plan _______________________________
Date of Review/Modification of Section 504 Plan ________________
Date of Intervention Plan ____________________________________
Target Date for Next Review _________________________________
4

Intervention Plan
Mitigating factors, such as medicine or other strategies that eliminate or reduce the effect of impairment on a major life activity, may NOT rule out eligibility for Section 504. This is a change under the new law.
Academic and/or Behavior intervention plan followed by the general classroom teachers.
Offer to reconvene team at a later time to review the student’s academic and behavioral performance or changes in a medical impairment and to reassess his or her eligibility or Section
504.
Clarify that the provision is designed to meet individual educational needs of handicapped persons as adequately as the needs of nonhandicapped persons are met in the least restrictive environment.
No qualified handicapped student shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any academic, research, occupational training, housing, health insurance, counseling, financial aid, physical education, athletics, recreation, transportation, other extracurricular, or other activity to which any other nondisabled student can participate. Providing the opportunity to participate – making it available as it is with all nondisabled students – but it is beyond reasonable and may be damaging to the student for the school to constantly approach a student about participating in each and every activity, event, club or organization that is available.
Discrimination is to deny access to or participation in or benefit from services. The school, by law (Sec.104.52) “may not, on the basis of handicap afford a qualified handicapped person with benefits or services that are not equal to that offered nonhandicapped persons…”
Sec.104.37 requires a recipient to provide nonacademic and extracurriculuar services and activities in such manner as is necessary to afford handicapped students an equal opportunity for participation. Because these services and activities are part of a recipient’s education program, they must, in accordance with this provision, be provided in the most integrated setting appropriate.
Reasonable accommodation is the standard.
The school’s current harassment policy and procedure is in place for all students and will be utilized to deal with any issues for any and all students.
5