REQUEST FOR ACCOMMODATIONS UNDER SECTION 504 of …
REQUEST FOR ACCOMMODATIONS UNDER SECTION 504 of the REHABILITATION ACT of 1973 2013-2014 SCHOOL YEAR
Student's Name: Last:
_______________ First: _____________________________________Middle: _____________
Male: ______ Female: _____
D.O.B: _____________________ I.D. #: ________________________________________________________
Borough:
District: ________ School:
_____________________ Grade: _____ Class: ____________
School Address: _______________________________________________________________________________________ Zip Code: ___________
Physician's Statement for Requested 504 Accommodations (if applicable):
1. Describe the nature of the concern: ____________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
2. Medical Diagnosis/Disability/ICD-9 code: _______________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
3. Describe how the disability affects the student's educational performance: _____________________________________________________________
___________________________________________________________________________________________________________________________
4. List/describe the educational service(s) that are being requested: ____________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Physician's Name (Print)
____________
______________________________________________________
Physician's Signature
Date Signed
Physician/Clinic's Address
___________
_______________________________________________________ NYS Registration No.
_________________________
Zip Code
____
________________________
Physician/Clinic's Telephone No. Physician/Clinic's Fax No.
____________________________ NPI No.
________________ Medicaid No.
Parent's Statement for Requested 504 Accommodations:
1. Describe the nature of the concern: ____________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________
2. Describe how the disability affects the student's educational performance: _____________________________________________________________
___________________________________________________________________________________________________________________________
3. List/describe the 504 accommodations that are being requested: _____________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________
To determine whether 504 accommodations are necessary, a 504 team will convene to review your request. If a 504 Accommodation Plan is necessary it will be completed by the school with your input. This plan must be reviewed annually.
By submitting this Request for 504 Accommodations, I am requesting that my child be provided with specific educational accommodation(s)) by the New York City Department of Education (the "Department"). I have provided the full and complete information regarding this request for educational accommodation(s) in this form. I understand that the Department, its agents, and its employees involved in the provision of the above-requested accommodation(s) are relying on the accuracy of the information that I have provided in this form to determine whether and to what extent my child will be provided with accommodations under Section 504.
Please Print Parent/Guardian's Name & Address Below:
________________________________________________ Parent/Guardian's Signature ________________________________________________ Date Signed ________________________________________________ Daytime Telephone No.
____________________________________________________________ ____________________________________________________________ ____________________________________________________________
REQUEST FOR ACCOMMODATIONS UNDER SECTION 504 OF THE REHABILITATION ACT OF 1973 2013-2014
DO NOT WRITE BELOW (FOR NYC DEPARTMENT OF EDUCATION USE ONLY)
Student's Name: ____________________________
Reviewed by: ________________________________ Name (Please Print)
Request for Educational Service(s) Approved ________
Denied ________
Reason Request Approved or Denied:
OSIS No:____________________________
___________________________________
Title
Date
Referred for Further Review _______
Referred to CSE/IEP Team ___________________
Date of Referral ________
_____________________________ Signature
13-14
Sent to School 504 Coordinator _____________
Date of 504 Team Mtg. ________
______________ Date
................
................
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