504 Forms.doc - DOC by avw11153

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									                         WAVERLY-SHELL ROCK COMMUNITY SCHOOLS

                                REFERRAL FOR 504 CONSIDERATION

Date Received:
Name of Student:                                                  D.O.B.:


Name of School:                                                    Grade:
Referring Person/Agency:                                           Position:
Reason for Referral:




Attendance: This student has been absent                                   days out of
                                 Days of school this year.


Grades: List current grades and subject




Testing Data: May include most recent achievement/aptitude testing such as NWEA, CSAP, QRI-III, etc.

Test:                                                   Result:

Test:                                                   Result:

Test:                                                   Result:




Academic Characteristics: Indicate by placing an X in front of the areas in which the student has difficulty:



504 Forms – Waverly-Shell Rock Community Schools                                                                1
                        WAVERLY-SHELL ROCK COMMUNITY SCHOOLS

Oral Reading:           Spelling                     Reading Comprehension

Math calculations                  Basic Reading skills           Math Reasoning

Written Expression                 Legible writing

                       REGULAR EDUCATION MODIFICATIONS OR ADJUSTMENTS

Check modifications and alternatives that have been used with this student:       Modified instructional methods
         Modified instructional pacing           Modified instructional materials         Behavioral planning or
contracting      Parent conferences      Environmental modifications              Other:

What were the results of these modifications?


Teacher Observations:
Based on your knowledge and observations, please rate this student’s performance in the following areas:
Observation Unsatisfactory Excellent Classroom work 1 2 3 4 5 Homework 1 2 3 4 5
Tests 1 2 3 4 5 Following oral instructions 1 2 3 4 5 Following written instructions 1 2 3 4 5
Attention Span 1 2 3 4 5 Organizational skills 1 2 3 4 5 Peer Relations 1 2 3 4 5


Summary of Parental Information (if available)




Summary of other findings or recommendations:




Signature of Team Contact Person
Eligibility Determination Form

I. General Information

Student Name: _____________________________ Date________________________
School ____________________________           D.O.B. :____________________
Grade: _________ Parent’s Name(s):_______________________________________

II. Reason for Meeting

        Initial evaluation
        Periodic re-evaluation
        Re-evaluation prior to significant change of placement



504 Forms – Waverly-Shell Rock Community Schools                                                               2
                           WAVERLY-SHELL ROCK COMMUNITY SCHOOLS

     Based on a summary of evaluation data (information from a variety of sources,
     including, if relevant, any aptitude or achievement testing, teacher recommendations,
     physical conditions, medical concerns, background as reported or documented,
     behaviors as observed or evaluated, etc.) the following eligibility determination has
     been made.


     III. Eligibility Criteria and Determination

            Yes            No Student has a mental or physical impairment.
            Yes            No Student’s impairment substantially limits a major life activity.
                                    Learning
                                    Walking
                                    Seeing
                                    Hearing
                                    Speaking
                                    Breathing
                                    Caring for one’s self
                                    Performing manual tasks

IV. Committee Members and Titles (members may not be present but had input into process)
_________________________________        ________________________________
_________________________________        ________________________________
_________________________________        ________________________________



V. Record of Action

 Date                   Action

____/____/____     Parents/Guardians provided written notice of rights
____/____/____     Parents/Guardians provided notice of 504 Evaluation and committee
                         meeting




     504 Forms – Waverly-Shell Rock Community Schools                                            3
                               WAVERLY-SHELL ROCK COMMUNITY SCHOOLS
                                      Notification Letter to Parents
                                                          (Option 1)

Date:_______________

Dear Parent or Guardian,

         This letter is to inform you that we are concerned about how ______________________ is progressing in school. We
have attempted a variety of accommodations for your child and would like to proceed further by evaluating your child for
accommodations he/she may be eligible for under Section 504 of the Rehabilitation Act. As part of our efforts to help improve
your child’s classroom performance, I have asked members of our Child Study Team to collect and review information on your
child’s progress. The teacher(s), guidance counselor, school psychologist, school nurse and other staff members may be
involved in this process. (This is not a Special Education referral)
         Once this information has been gathered and reviewed, we will request a meeting with you to discuss plans to help
meet your child’s needs.
         You are provided specific rights concerning this process, which are designed to keep you fully informed concerning
decisions about your child. Your 504 rights are summarized on the back of this form.
         If you have questions, please contact ____________________________________ at
____________________________.                              (504 Case Manager)
     (school and phone)

        Sincerely,




        Yes, I have been informed of and received a copy of my rights under Section 504



_____________________________________________                    _____________________
         (Signature of Parent or Guardian) (Date)
                                WAVERLY-SHELL ROCK COMMUNITY SCHOOLS

                               PARENT NOTICE OF SECTION 504 CONFERENCE
                                               (Option 2)

Date: __________________


Dear ________________________________,

You are invited to attend a conference for your son/daughter _______________________________,
     Student’s name
on ____________, _________________, at ____________________________________________
      date                  time                        place


The purpose of this meeting is to:
                Review your child’s records and determine whether he/she is eligible for a Section 504 Plan. If eligible, a
                Section 504 Plan will be developed at this time.
                Review your child’s Section 504 Plan and discuss the following:



                        □   Transition
                        □   Student Progress
                        □   Re evaluation
                        □   Other: ______________________________________



The following persons are invited to this conference:

                 Section 504 Case Manager
                 School Psychologist
                 Teacher(s)
                 Guidance counselor
                 Parent
                 School Nurse
                 Administrator
                 Other: ___________________________



We look forward to having you participate in this meeting. Please call me at ________________________ if you have any
questions concerning this conference.

Sincerely,




_________________________________________________
    Section 504 Case Manager
                              WAVERLY-SHELL ROCK COMMUNITY SCHOOLS
                                    504 SERVICE DELIVERY PLAN
                                             (Option 1)

NAME:_____________________________                         SCHOOL:_____________________
D.O.B _____________________________                      GRADE LEVEL:________________
PARENT(S): ________________________                        _____________________________
Evaluation: ________________________________                  Date: ______________________________
Evaluation: ________________________________                  Date: ______________________________
Evaluation: ________________________________                  Date: ______________________________
Disability: _________________________________                 Date: ______________________________

1. Describe the nature of the concern: ___________________________________________________
        ________________________________________________________________________________
       ___________________________________________________________________

2.     Describe the basis for determination of handicap: _________________________________________
       ___________________________________________________________________
       ___________________________________________________________________

3.      Describe how the handicap affects a major life activity: ____________________________________
        ________________________________________________________________________________
        ________________________________________________________________________________

4.     The TAT Team has reviewed information on the above named student and concludes that he/she meets the eligibility
        criteria under Section 504 of the 1973 Rehabilitation Act. In accordance with the Section 504 guidelines, the school
        has agreed to make reasonable accommodations and address the individual needs
        by:

PHYSICAL ARRANGEMENT OF ROOM:
_____   seating student near the teacher
_____   seating student near a positive role model
_____   standing near the student when giving directions or presenting lessons
_____   avoiding distracting stimuli ( air conditioner, high traffic areas, etc.)
_____   increasing the distance between desks
_____   additional accommodation : _____________________________________________________________

LESSON PRESENTATION:
_____   pairing students to check work                   _____     providing written outline
_____   writing key points on board                   _____    allowing student to tape record lessons
_____   providing peer tutoring                             _____      having child review key points orally
_____ providing visual aides                                _____     teaching through multi-sensory modes
_____   providing peer notetaker                             _____      using computer-assisted instruction
_____   making sure directions are understood
_____   breaking longer presentations into shorter segments
_____   additional accommodation: _____________________________________________________________

ASSIGNMENTS/WORKSHEETS:
_____  giving extra time to complete tasks                  _____   using self-monitoring devices
_____  simplifying complex directions                      _____   reducing homework assignments
_____  handing worksheets out one at a time                 _____    not grading handwriting
_____  reducing reading level of assignments
_____  requiring fewer correct responses to achieve grade
_____  allowing student to tape record assignments/homework
_____  providing a structured routine in written format
_____  providing study skills training/learning strategies
_____  giving frequent short quizzes and avoiding long tests
_____  shortening assignments; breaking work into smaller segments
                                WAVERLY-SHELL ROCK COMMUNITY SCHOOLS
_____     allowing typewritten or computer printed assignments
_____     additional accommodation: _____________________________________________________________

TEST TAKING:
_____   allowing open book exams                               _____ allowing extra time for exams
_____   giving exams orally                                    _____  reading test items to student
_____   using more objective responses                         _____  giving take home tests
_____   allowing student to give test answers on tape recorder
_____   giving frequent short quizzes, not long exams
_____   additional accommodation: _____________________________________________________________

ORGANIZATION:
_____  providing peer assistance with organizational skills
_____  assigning volunteer homework buddy
_____  allowing student to have an extra set of books at home
_____  sending daily/weekly progress reports home
_____  developing a reward system for in-school work and homework completion
_____  providing student with a homework assignment notebook
_____  additional accommodation: _____________________________________________________________

BEHAVIORS:
_____  praising specific behaviors                          _____       allowing legitimate movement
_____  using self-monitoring strategies                     _____       contracting with the student
_____  giving extra privileges and rewards                  _____      increasing the immediacy of rewards
_____  keeping classroom rules simple and clear             _____     implementing time-out procedures
_____  making “prudent use” of negative consequences
_____  allowing for short breaks between assignments
_____  cuing student to stay on task (nonverbal signal)
_____  marking student’s correct responses, not mistakes
_____  implementing a classroom behavior management system
_____  allowing student time out of seat to run errands, etc.
_____  ignoring inappropriate behaviors not drastically outside classroom limits
_____  additional accommodation: _____________________________________________________________

MEDICATION:
 name of physician: _______________________________________ phone: ______________________
medication(s): ____________________________________ schedule: __________________________
       ____________________________________ schedule: ___________________________
monitoring of medication(s) ____________ daily _____________ weekly _____________ as needed
administered by: _______________________________________________________________________

SPECIAL CONSIDERATIONS:
_____   suggesting parenting program(s)                           _____       alerting bus driver
_____   monitoring student closely on field trip             _____      suggesting agency involvement
_____   provide social skills group experiences               _____       providing group/individual counseling
_____   inservicing teacher(s) on child’s handicap
_____   developing intervention strategies for transitional periods (e.g., cafeteria, physical education, etc.)

DISCIPLINE:
□ This student’s Section 504 disability would not cause him/her to violate school rules.

□ This student’s Section 504 disability would cause him/her to violate school rules.
(If second box is checked, fill out Behavior Modification Disciplinary Plan)

Participants: (Name and Title)
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
Case manager’s signature: _____________________________________________________________________
                                       WAVERLY-SHELL ROCK COMMUNITY SCHOOLS
                                                  SECTION 504 PLAN
                                                      (Option 2)
                                                                                               Date of Meeting:_________________

                                                                                                              Not Eligible:
Name:______________________________              Student     ID    #:___________________      Birthdate:_____________
       Grade:____________
         Last      First     Initial
School Attending:___________________________________________________________________________________________
Parent(s)/Guardian:__________________________________________________________________________________________
Address:__________________________________ City:__________________ State:__________ Zip:_______________________
Home Phone:_________________ Father’s Work Phone:_____________________ Mother’s Work Phone:____________________
Student Address:____________________________ City:___________________ State:__________ Zip:______________________
Primary Language/Mode of Communication of Student:____________________ Other Language(s):_________________________
Primary Language/Mode of Communication in the Home:___________________ Other Language(s):________________________


PARTICIPANTS IN MEETING
Print Name:        `                                                                Print Title:




Parent/guardian:

Student (as appropriate):___________________________________________________________________________
Individual providing the parent/guardian with the procedural safeguards Section 504 Parent/Student Rights In
Identification, Evaluation And Placement:


                   Print Name                                                                         Title


DATA REVIEWED:
  Parent Information                     Student Work Samples                      Speech/Language Evaluation
  Teacher Information                    Standardized Test Results                Special Education Evaluation
  Medical Information                    Discipline Record                         Psychological Evaluation
  Attendance Records                     Classroom Accommodations                  Report Cards
  Private Evaluation                     Social Work Report                         Observations

   Behavior Assessment/Behavior Plan                 Information relating to current home/community behavior

         Prior Section 504 Student Service Plan; Date of Plan:_________________

         Other: specify:_________________________________________________________________________

Note: A copy of the data considered at the meeting must be maintained in the student’s cumulative
record.
Copy:    Parent/Guardian                    School staff, as appropriate
         Student’s cumulative record        504 Compliance Officer
                               WAVERLY-SHELL ROCK COMMUNITY SCHOOLS


Department of Student Services
SECTION 504 PLAN
                                                             Date of Meeting:________________
________________________________________________ ___________________ _______________________
       Legal Name of Student                                         Birthdate                     Grade
1. Does the student have an impairment?       Yes           No Describe in detail:-
   __________________________________________________________________________________________
   __________________________________________________________________________________________
   __________________________________________________________________________________________
   __________________________________________________________________________________________
2. Is the impairment substantially limiting?   Yes          No Describe in detail:-
   __________________________________________________________________________________________
   __________________________________________________________________________________________
   __________________________________________________________________________________________
   __________________________________________________________________________________________
3. Does the impairment substantially limit one or more major life activities?
       Yes              No           If yes, check all that apply:
         caring for oneself     performing manual tasks              walking         seeing breathing
          hearing               speaking                    working           learning


4. Because of the disability is the student unable to receive the programs and benefits of the district as adequately as
   non-disabled peers?      Yes          No Describe:
   __________________________________________________________________________________________
   __________________________________________________________________________________________
   __________________________________________________________________________________________

If yes: the student is eligible for protection under Section 504.

                      ACCOMMODATIONS AND SERVICES TO ACCESS THE CURRICULUM

Student
Need:_______________________________________________________________________________
Accommodations/Service:_______________________________________________________________
______
Responsible
Person:__________________________________________________________________________

Student
Need:_______________________________________________________________________________
Accommodations/Service:_______________________________________________________________
______
Responsible
Person:__________________________________________________________________________

Student
Need:_______________________________________________________________________________
Accommodations/Service:_______________________________________________________________
                               WAVERLY-SHELL ROCK COMMUNITY SCHOOLS
______
Responsible
Person:__________________________________________________________________________

Student
Need:_______________________________________________________________________________
Accommodations/Service:_______________________________________________________________
______
Responsible
Person:__________________________________________________________________________
Copy:    Parent/Guardian




Student’s cumulative record




School staff, as appropriate




504 Compliance Officer
                                WAVERLY-SHELL ROCK COMMUNITY SCHOOLS

                                       Department of Student Services
                                           SECTION 504 PLAN
                                                                          Date of Meeting:_______________


 ________________________________________________ ___________________ _______________________
        Legal Name of Student                                 Birthdate                   Grade


                                               ADDENDUM

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 Copy: Parent/Guardian
Student’s cumulative record
School staff, as appropriate
504 Compliance Officer

								
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