Microsoft Word - Section 504 Eligibility and Accommodation ...



DAVID DOUGLAS SCHOOL DISTRICTStudent Services DepartmentDate: _______________ FORMTEXT Date of Initiation of Plan: _______________ FORMTEXT SECTION 504 ELIGIBILITY AND ACCOMMODATION PLAN FORMTEXT Student: _________________ Building: ______________ FORMTEXT DOB: __________ FORMTEXT Grade: __________ FORMTEXT Disability Documentation: NOTE: Do not consider mitigating circumstances in answering these questions. 1. The student has or is believed to have a physical or mental impairment. Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT If yes, what is it? _____________________________________________________________________________? A written medical notice documenting the physical or mental impairment is provided by the appropriate medical or health care professional. Yes FORMCHECKBOX FORMTEXT No FORMCHECKBOX If yes, date of notice? _____________________________________________________________________________List and attach all medical reports, evaluations, test results, or other pertinent information: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ FORMTEXT 2. The impairment substantially limits one or more of the student’s major life activities (without regard to mitigating measures, except for eyeglasses or contact lenses). Yes FORMCHECKBOX No FORMCHECKBOX If yes, what is the basic life activity (or activities) affected? ______________________________________________________________________________ FORMTEXT How is it “substantial?” FORMTEXT __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Accommodation Plan:Note: May consider mitigating circumstances in determining whether a plan is needed. Does the student need accommodations to access the benefits of public education as adequately as the needs of nondisabled students are met? Yes FORMCHECKBOX No FORMCHECKBOX If yes, list below: Accommodations/AdaptationsResponsibilityLocationSignature of Team MembersTitleAgreeDisagreePeriodic Review: Parent agreement required for initial 504 planDateContinue Plan (Comments)CounselorParent(s)(Significant changes should be written on a new form and attached to the originals). ................
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