SECTION 504 REFERRAL FOR ELIGIBILITY/SERVICES

Student Name: __John Doe_________________________________________________________ Date of Birth: __5/5/05___________

Grade: _8th____________________________________ Teacher: ___Mrs. Smith_________________________________

Statement of Suspected Section 504 Disability: I am concerned that this student may have a physical or mental impairment which substantially limits one or
more of the major life activities. Major life activities include, but are not limited to, caring for one’s self, performing manual tasks, walking, seeing, hearing,
speaking, breathing, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, communicating, working, and learning, or the operation of a
major bodily function, including but not limited to, functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory,
circulatory, or endocrine functions.

Nature of the concern: Describe the student’s need or area of concern, including which major life activity is being limited and how the major life activity is being
limited. Include any relevant medical information, if available.

Check the major life activity that is affected by the impairment:

□ seeing □ hearing □ caring for one’s self □ working
□ walking X learning □ performing manual tasks □ standing
X eating □ sleeping □ speaking □ reading
□ lifting □ bending □ communicating □ major bodily function: ___________
X thinking X concentrating □ breathing

*Note: The determination of whether and impairment substantially limits a major life activity must be made without regard to the ameliorative effects of
mitigating measures such as medication.
Explain:
John has been diagnosed with Crohn’s disease for about one year. John’s Crohn’s disease is poorly controlled, and he suffers from frequent flare ups. John
may have a difficult time eating due to feeling nauseated and having stomach pain. John’s stomach pain may also make it difficult for him to concentrate, learn, or
think at times. John may require frequent trips to the restroom or school nurse. John will also need excused from class for treatments, follow up office visits with
his specialist, and may need to stay home during times of moderate-severe flare ups.

Name of person submitting referral: ________________________________Date of signature: ______________ Relation to student: ________________

Contact information: __________________________________________________________________________________________________________

Please submit to the building 504 Coordinator: (Name) ___________________________________________________________________

Date Received: _________

504 Coordinator Initials: _________

 SECTION 504 PLAN

Student Name: John Doe________________________ Date of Birth: 5/5/05_____________ Plan Start Date: 8/25/2018___________

Grade: _8th______________________________________ Teacher: _Mr. Smith_________________ Plan End Date: 6/5/2019_________

Date of Eligibility Determination: _______________________ Reevaluation Due Date: ____________________________________

Area of disability and explanation of how disability substantially limits a major life activity: John’s crohn’s disease may cause moderate to severe
stomach pain and nausea. This stomach pain and nausea may distract John from being able to concentrate, think, and learn. John may also require
frequent trips to the restroom or nurse’s office. Crohn’s disease requires frequent follow up office visits with a specialist, office visits for treatments,
and may cause John to be absent due to flare ups.

Required Support/Accommodation Setting Responsible Party Area of Impact

Please provide John with an “anytime” Classroom Teacher- Mr. Smith Learning
bathroom pass that he may use with out
restriction, penalty, and with out needing to ask
permission first.

Please allow John to go to the nurse’s office as Classroom Teacher- Mr. Smith Learning
frequently as he requests for stomach
pain/nausea and/or to receive medication.

Please allow John to have extra time to Classroom Teacher- Mr. Smith Learning
complete assignments or tests if he is
complaining of stomach pain or nausea.

Please provide John with written lectures that Classroom Teacher- Mr. Smith Learning
he can review at home if he is complaining of
stomach pain or nausea. He may not be able to
concentrate during class due to pain/nausea.

Please excuse John’s absences from class and Classroom Teacher- Mr. Smith Learning
provide John with any assignments, notes,
tests, projects, and/or any school work he may
have missed while absent.
Participation in state and district-wide assessments: □ No Accommodations
X Accommodations as indicated on the following pages
 SCHOOL NAME
SECTION 504 PLAN (Continued)
CLASSROOM, STATE AND DISTRICT ASSESSMENTS

X Classroom Assessments X State Assessments X District Assessments

Test Areas Accommodations Test Areas Accommodations

Reading _____ Small group administration Science _____ Small group administration
__X___ Extended time for test ___X__ Extended time for test
_____ Directions read orally/repeated _____ Test read
_____ Dictation _____ Dictation
__X___ Other Please allow frequent restroom breaks without penalty _____ Clarify directions
__X___ Other Please allow frequent restroom breaks without penalty

Math _____ Small group administration Social Studies _____ Small group administration
__X___ Extended time for test __X___ Extended time for test
_____ Test read _____ Test read
_____ Dictation _____ Dictation
_____ Clarify directions _____ Clarify directions
__X___ Other Please allow frequent restroom breaks without penalty __X___ Other Please allow frequent restroom breaks without penalty

Writing/Language _____ Small group administration Other _____ Small group administration
__X___ Extended time for test __X___ Extended time for test
_____ Test read _____ Test read
_____ Dictation _____ Dictation
_____ Clarify directions _____ Clarify directions
__X___ Other Please allow frequent restroom breaks without penalty ___X__ Other Please allow frequent restroom breaks without penalty
 JUSTIFICATION FOR ACCOMMODATIONS: John may require extra time due to time lost while John was in the restroom. John
may also need extra time due to inability to concentrate or think if John is suffering from stomach pain and/or nausea.

Assistive Devices: Related Services:

PARTICIPANTS:

Printed Name Signature Title Date Agree Disagree

Parent

* Those who check “disagree” must attach a statement explaining the reason.
The disagreement does not exclude them from implementing accommodations.

Copy of plan: Parent/Legal Guardian, Pupil Personnel, 504 Coordinator/Providers Responsible, Confidential Student File