SECTION 504 OF THE

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					    Milltown Primary
School
                                 SECTION 504 OF THE
                              REHABILITATION ACT OF 1973

                                        REFERRAL FORM

Section 504 of the Rehabilitation Act of 1973 defines an “individual with a disability” as any person
who (a) has a physical or mental impairment which substantially limits one or more major life
activities, (b) has a record of such an impairment, or (c) is regarded as having such an impairment.

Major life activities include taking care of one’s self, performing manual tasks, walking, seeing,
hearing, speaking, breathing, learning and working.

I.      Personal Information (Please type or print)

        Student: Gillian Cushing                       Date of Birth: xx/xx/xx
        Parent: Mr. & Mrs. Cushing                              Phone No. (xxx)xxx-xxxx
        Address: xxxxxxxx                              School: Milltown
        Teacher:    Ms. xxxxxxxxxx                              Grade: 4th
II.     Background Information

        A.         Reason for Referral: Gillian is being referred at the request of her parents due to her
                   diagnosis of Celiac Disease.

        B.         Strategies/Interventions To Date: In previous years Milltown School accommodated
                   the requests of Mrs. Cushing by:
                    At the request of the School Nurse classroom celebrations were gluten free.
                    Classroom teachers have also been instructed about the nature of Celiac Disease.
                    Wipes have been provided for Gillian to use in the classroom to keep her desk
                        clean throughout the day.
                    Wipes have been available in the cafeteria and Gillian’s table has received extra
                        cleaning.
                    Gillian has access to the bathroom throughout the day and can use the Nurse’s
                        office if needed.
                    Gloves have been provided in the Art room and classroom when working with
                        Play-Doh or paper mache.
                    Parents receive immediate notification if Gillian exhibits any adverse symptoms,
                        such as abdominal pain.

        C.         Comments (Please feel free to attach relevant information)

                   Referred by:      Mrs. Cushing
                                     Print Name
                              Signature                              Date of Referral




    Milltown Primary
School

Dear Parent(s)/Guardian(s):

You have referred your child to the 504 Evaluation Committee of Milltown School for
determination of eligibility of services under Section 504 of the Rehabilitation Act of
1973.

Under this act the school has a responsibility to evaluate any child who, because of a
handicap, needs or is believed to need education accommodations or related services.

This evaluation will be conducted by a group of persons knowledgeable about your
child. This group known as the 504 Evaluation Committee will review all evaluative
data available, interview teachers, interview the parent/guardian and request additional
relevant information and reports when appropriate.

A booklet explaining your rights under Section 504 is enclosed for your reference.

Please feel free to contact the building principal if you have any questions regarding
the 504 process.

Sincerely,


504 Evaluation Committee
Milltown School

Enclosure

CC: 504 Coordinator – Ms. xxxxxxxxxx
    Milltown Primary
School
           SECTION 504 OF THE REHABILITATION ACT OF 1973
                       ACCOMMODATION PLAN


Student Name: Gillian Cushing                              Date: 1/26/10

Address: xxxxxxxxxxxx                                      Date of Birth: xx/xx/xx

School: Milltown                                           Grade: 4th

                                                           Teacher: Ms. xxxxxxxxxx


Accommodation Plan:

      In the event of excessive trips to the restroom (out of the classroom for 3
       hours) one hour of instruction will be provided. In the case of excessive
       absences (10 consecutive days with a prognosis of additional days absent) due
       to illness related to Celiac Disease, home instruction will be considered.
      General: All Staff members involved in the care and education of Gillian
       must receive training in the management of Celiac Disease. Each substitute
       school teacher and substitute school nurse will be provided with written
       instructions regarding Gillian’s Celiac Disease plan of care. Benedryl will be
       kept in the Nurse’s office and will be made available to Gillian should
       accidental exposure occur, as hives can appear when cross contamination
       occurs.
      Classroom: Teachers will give Gillian’s parents a 48-hour notice of any
       special events outside the classroom at which food will be prepared that is not
       from the cafeteria. Snacks will be available in the classroom, or Gillian’s
       backpack, or the nurse’s office (whichever is deemed the most viable) in the
       event that she becomes hungry. If the school is providing food for the
       students, gluten free food will be provided by the school for Gillian.
      Cafeteria: The school will designate a person to be responsible for ensuring
       that lunch tables and surrounding areas are thoroughly cleaned before lunch
         with a dedicated container of wipes. The cafeteria will continue to have
         gluten-free foods available for lunch.
        Gluten free lunch options will be made available to Gillian on a daily basis.
         The appropriate health measures will be executed by the Maschio staff after
         training by their supervisor.
        Bathroom: Gillian shall be permitted to use the bathroom without restriction.
         If she deems it necessary, she will be permitted to use the bathroom in the
         nurse’s office in case of serious stomach cramping and cold sweats, so that
         she can be overseen by an adult.
        Art/Art Projects: Disposable gloves will be accessible to Gillian for projects
         that contain gluten such as play doh or paper-mâché. School projects
         utilizing glutinous ingredients which can become airborne (i.e. flour or paper-
         mâché dust) must be substituted with another project or gluten-free
         ingredients, such as gluten free flour. The staff should call Mrs. Cushing if
         they have any questions about projects that may include gluten.
        Field Trips: Parents will be notified of upcoming field trip plans that would
         involve food or food related activities. The school staff will provide
         reasonable notice to her parents when there will be a change in planned
         activities such as field trips or parties. If the school is providing food for the
         students, gluten free food will be provided by the school for Gillian.
        Parental Notification: Gillian’s parents should be notified immediately in the
         following situations:
              *The student has eaten a food item that contains gluten
             *The student has symptoms of gluten ingestion such as abdominal pain,
         cramping, diarrhea or hives.
        Emergency Situations: Gillian’s parents shall provide the school with a three
         day emergency supply of non-perishable gluten-free foods.


Accommodation Plan Participants:

Parents:                Mr. and Ms. Cushing

Teachers:               Mrs. xxxxxxxx

Principal:              Mr. xxxxxxxx

Nurse:                  Mrs. xxxxxxxx
School Psychologist: Mrs. xxxxxxxx
School Counselor:       Mrs. xxxxxxxx
    Milltown Primary
School
                      DETERMINATION OF ELIGIBILITY
                        [Evaluation provided by school]


Based upon the above assessment results, it has been determined that Gillian has a
physical or mental disability which substantially limits one or more major life
activities and that he/she is in need of educational accommodations or related services.
Therefore, she/he is eligible for services under Section 504 of the Rehabilitation Act of
1973.


Evaluation Participants:

            TITLE               PRINT/TYPE NAME                    SIGNATURE


Parent/Guardian



Teacher(s)




Principal



Nurse



Other(s)
            Milltown Primary School
             SECTION 504 OF THE REHABILITATION ACT OF 1973
                      EVALUATION SUMMARY AND
                    DETERMINATION OF ELIGIBILITY

Student Name: Gillian Cushing                              Date: 1/26/10

Address: xxxxxxxxxx                                        Date of Birth: xx/xx/xx

School: Milltown                                           Grade: 4th

                                                           Teacher: Ms. xxxxxxxxxx

                              EVALUATION RESULTS
                            [Evaluation provided by school]

Educational
On the NJ ASK 3 Gillian performed very well. She scored in the Advanced Proficient
range in Mathematics (291) and solidly in the Proficient range (228) in Language Arts.

In the classroom, Gillian is performing at or above grade level in all areas. She is a
thoughtful writer, loves to share her writing pieces, and contributes many ideas to her
classmates. Gillian is an avid reader and participates in all discussions about what she is
reading in all subjects. In Math, Gillian picks up concepts quickly, likes immediate
feedback, and enjoys sharing her work on the whiteboard. She is continuing to work on
her math facts. Gillian has a great sense of humor. She "sees" the humor in many things
around her and doesn't hesitate to share with others. Gillian loves working in groups and
is very proud of her role as a Girl Scout where her leadership abilities can continue to
grow.

At this time Gillian does not require any accommodations in the classroom to support her
learning.

Medical
      Hearing and Vision
      -- Vision 20/30 near and far both eyes
      -- Muscle balance/fusion/plus lens- pass
      -- Normal exam
      -- Hearing- pass at 20db
      -- Heard all frequencies
      -- Height 49 ¾” - Weight 56 lbs.
Medical History: Celiac disease is an autoimmune disease that causes damage to the
intestinal lining, interfering with the absorption of nutrients. Untreated, celiac disease
causes multi-system complications such as diarrhea, constipation, gas, bloating, iron
deficiency anemia, decreased bone density, failure to thrive, short stature, and behavior
problems. The only treatment for celiac disease is a strict gluten free diet for life. Gluten
is found in wheat, rye, barley and contaminated oats. Therefore, all foods with wheat, rye,
barley and oats must be eliminated from the diet. In addition to the foods being gluten
free, it is equally important that these foods are not contaminated by coming in contact
with gluten containing foods during their preparation or service. Celiac disease is an
autoimmune disease that causes damage to the intestinal lining, interfering with the
absorption of nutrients. Untreated, celiac disease causes multi-system complications such
as diarrhea, constipation, gas, bloating, iron deficiency anemia, decreased bone density,
failure to thrive, short stature, and behavior problems. The only treatment for celiac
disease is a strict gluten free diet for life. Gluten is found in wheat, rye, barley and
contaminated oats. Therefore, all foods with wheat, rye, barley and oats must be
eliminated from the diet. In addition to the foods being gluten free, it is equally important
that these foods are not contaminated by coming in contact with gluten containing foods
during their preparation or service.

Celiac disease is a disorder that causes problems in your intestines when you eat gluten.
Gluten damages the intestines of people with Celiac Disease. Once the damage occurs,
patients with celiac disease have difficulty absorbing vitamins, calcium, protein,
carbohydrates, fats, and other important nutrients. This can lead to weight loss,
malnutrition and anemia.
Gillian experienced very frequent stomach pain/Irritable Bowel type symptoms. Lack of
growth for three years prior to diagnosis.
Diagnosed with Celiac Disease in 2007. Gillian continued to experience pain and
irritable bowel symptoms throughout the second and third grade. She needed to spend a
lot of time in the bathroom during the school day. She appears much improved in fourth
grade. She takes no medications at this time - however, she must follow a strict gluten-
free diet for the rest of her life.
Physical - No physical restrictions. Gillian is small in both height and weight when
compared to her same aged peers. She has grown 4 ¼” and gained 12 pounds since being
diagnosed.
Adaptive Behavior
Gillian is able to:
*monitor her diet and avoid eating foods that contain gluten
*wipe down her desk/table with a dedicated container of wipes
*inform the teacher that she needs to go to the nurse during a flare up of stomach pain

				
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