Fillable SECTION 504 INDIVIDUAL ACCOMMODATION PLAN (IAP)

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SECTION 504 INDIVIDUAL ACCOMMODATION PLAN (IAP)

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SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
17/26/2018
: Complete the form for students with a 504 disability requiring accommodaon(s):
• Accommodaon(s) does not change the construct being measured by the test
• Student receives the accommodaon(s) in the classroom on a regular basis
• Accommodaon(s) must be entered at the local level and be reected in SIS
• Please refer to the LEAP 2025 Accommodaons and Accessibility Manual for LEAP 2025 and EOC guidance on the use of appropriate
accommodaons, access for all features, and accessibility features.


    
 
 

 English Spanish French Vietnamese Chinese Other:
 (Check all that apply): Idened impairment that substanally limits one or more major life acvies:
(More than one source of supporng data needed. Aach any addional informaon.)

Documentaon of evidence-based intervenon(s) should be provided.
 (Bullen 1903)

(Select all that apply):
Math Reading Other
If other, specify:
Cite evidence used in idencaon process. Aach any addional informaon.

Mulple sources of documentaon of characteriscs required.







(Specify):
Cite evidence used in idencaon process. Aach any addional informaon.

Evidence of diagnosis by authorized provider required.





 (expected 6+ months duraon)






(Specify):


If other, specify:
Specify all supporng data considered including doctor's name, diagnosis, and date of diagnosis as well as any other informaon used in the
eligibility determinaon process. Aach any addional informaon.

(27) (if appropriate) Yes No 

(28) (if appropriate) Yes No
(29) (if appropriate) Yes No
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
27/26/2018


   

*Below are accommodaons and modicaons that can be ulized within the classroom, classroom tests, and district assessments.
These should be aligned to the accommodaons for state assessments in Part I to the extent possible.
None. If no accommodaons are necessary, go directly to Part J.
 (Teachers responsible for the subjects checked must receive a copy of this IAP.)
Math Art/Music Computer Lab Vocaonal Elecves English Field Trips
Reading Spelling Physical Educaon Library
Social Studies Gied/Talented
Wring Science Health Other:
Specify the raonale for accommodaons for the indicated seng(s), including the data used to make the determinaon. Aach any addional informaon.
The listed accommodaons must be appropriate and must not subvert the purpose of the test.
The District 504 Coordinator should be consulted for appropriateness of other accommodaons not listed below.

(01) Assign preferenal seang (09) Change locaon to increase physical access
(08) Post or provide visual cues and/or markers (11) Stand near student when giving direcons/redirecon
(13) Instrucon: Individual, Small Group, or
Other, specify:
(07) Other
Specify reason:

(01) Use graphic organizers as teaching/learning tools (21) Do not count o for spelling when grading content
(03) Use teacher-iniated signal to redirect aenon (23) Computer-assisted instrucon
(05) Break tasks and procedures into sequenal steps (25) Alter format of materials on page (e.g., font/spacing/color)
(08) Modify assignments (e.g. vary length, limit number of items) (15) Use virtual/mulsensory modes to reinforce instrucon
(09) Color code material (36) Monitor assignments daily
(37) Provide study assistance (Select all that apply): Peer notes Photocopies of teachers notes Study guide Other
If other, specify:
(38) Assign (Select all that apply): Notetaker Peer tutor Scribe Work buddies Other
If other, specify:
(12) Provide opons for student to obtain informaon and demonstrate knowledge through use of (Select all that apply):
Alternate project Interviews Oral reports Dramazaon Mulple choice items Essay responses Other
If other, specify:
(13) Appropriate format for instruconal/supplemental materials (e.g. audio, digital, large print) (Specify):
(14) Other (Specify):

(01) Extended Time (Select all that apply): Classroom Homework Projects
If other, specify:
(02) Provide melines for compleng tasks in chunks (05) Provide assistance for transions (Specify):
(03) Allow breaks during work periods or between tasks (09) Other (Specify):
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
37/26/2018


   

(02) Establish procedures and rounes to help complete acvies (09) Tiered Posive Behavior Support Program
(04) Determine reason for behavior and teach replacement skills (12) Structured social skills training/formal instrucon
(05) Visits with counselor or other service personnel
(06) Develop, implement, and monitor a structured behavior intervenon plan (BIP) Note: Required for students who exhibit recurrent
problemac behavior and/or have repeated suspensions. (Behavior Intervenon Plan aached)
(07) Minimize triggers (Specify):
(08) Other (Specify):

(01) Manipulaves (08) Digital Recorder
(02) Organizers (09) Colored reading lters/overlays
(03) Highlighters/Markers (10) Adapted grips, pencils, utensils, other tools (Circle)
(24) Text to Speech Program (12) Electronic Scribe/Recorder
(06) Digital/Electronic Books (13) FM System
(25) Speech to Text
(11) Calculator **Only available for students with a disability that severely limits or prevents the ability to perform basic math calculaons
(i.e., student is unable to perform single digit addion, subtracon, mulplicaon, or division) even aer varied and repeated aempts to
teach the student to do so. Refer to the LEAP 2025 Accommodaons and Accessibility Manual**
Specify the math-related disability AND ALL data used to determine the appropriateness of the accommodaon. Aach any addional informaon.
(07) Word Processor with certain features (Select all that apply): Talking spell checker Grammar checker Word predicon Other
If other, specify:
(26) Other (Specify the technology needed and idenfy all of the data used to make this determinaon. Aach any addional informaon.)

(00)  Yes No (If no, proceed to Parts J and K)
(00)  Yes No (If yes, specify below)
 
(01) Prior noce of tests (27) Small Group Tesng
(12) Shortened tests (08) Alternate opons for demonstrang learning
(10) Allow student to write on tests (28) Individual Tesng
(02) Increased me for wrien projects:
If other, specify:
(09) Increased me for compleon:
If other, specify:
(05) Modied test format
I understand that the selected accommodaons must be appropriate and must not subvert the purpose of the test. I have consulted with the
District 504 Coordinator for the appropriateness of other accommodaons not listed above.
Specify modied test format recommended:
(15) Tests read aloud (Only available if a reading-related disability is indicated and the student is reading signicantly below grade level.)
 The required read aloud criteria are only needed for ELA. Refer to the LEAP 2025 Accommodaons and Accessibility Manual criteria for use on
state assessments in order to ensure alignment.
Specify the reading-related disability and all data considered when making the decision to provide this accommodaon. Aach any addional informaon.
Specify reading discrepancy:
If other, specify degree of decit:
Select One
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
47/26/2018
(As aligned with above accommodaons and disability)
*The accommodaons below must be aligned to the pracces within the classroom and must be in place 30 calendar days before the assessment.
If a student needs an accommodaon that is not noted below, a Unique Accommodaon Request must be submied to the LDOE for approval.

(01) Grades 3-8 State Assessments (02) LEAP 2025/EOC (Select all that apply):
English I, English II, English III, Algebra I, Geometry, Biology, US History
(03) ELPT
(00) None (Student does not need standardized tesng accommodaons or has completed all required tesng)
 Standardized tests, other than state tests, may have other spulaons for accommodaons. Please check with your DTC to access the specic
accommodaons criteria for each test.
Accommodaons such as those listed in Secons C through H enhance academic performance for many students. However, Secon 504
accommodaons are required for students with a learning, behavior, or health-related condion that signicantly reduces the student’s ability to
obtain a Free Appropriate Public Educaon.
Secon 504 accommodaons should be noted on this IAP only if they are consistently needed to provide this student equal access to educaonal
opportunies or to allow the student to learn and demonstrate learning despite his/her disability.
Students may receive standardized tesng accommodaons listed below if those accommodaons are rounely received during the instruconal
period and do not subvert the purpose of the test. Unique accommodaons not specically listed require approval using the Unique
Accommodaon Request Form.
Unique accommodaons require addional documentaon and LDOE approval 30 calendar days prior to state assessments.

   

Human Read Aloud Human Read Aloud Human Read Aloud Human Read Aloud
Kurzweil Kurzweil Kurzweil Kurzweil
Recorded voice le Recorded voice le Recorded voice le Recorded voice le

FM System FM System FM System FM System
Hearing Device Hearing Device Hearing Device Hearing Device
Interpreter Interpreter Interpreter Interpreter
Audio Amplicaon Audio Amplicaon Audio Amplicaon Audio Amplicaon
Communicaon Assistance (Script) Communicaon Assistance (Script) Communicaon Assistance (Script) Communicaon Assistance (Script)

Direcons Claried, Highlighng Tool, Headphones, Noise Buers, Redirect to the Test, and Extra White Paper are available to all students.
Large Print Large Print Large Print Large Print
Listening Device Listening Device Listening Device Listening Device
Color Overlay Color Overlay Color Overlay Color Overlay
Tacle Graphics Tacle Graphics Tacle Graphics Tacle Graphics

    

Text-to-Speech Text-to-Speech Text-to-Speech Text-to-Speech
Text-to-Speech (Except
Reading Comprehension
secons on the Eng III EOC)
Human Read Aloud Human Read Aloud Human Read Aloud Human Read Aloud
Human Read Aloud (Except
Reading Comprehension
secons on the Eng III EOC)

FM System FM System FM System FM System FM System
Hearing Device Hearing Device Hearing Device Hearing Device Hearing Device
Interpreter Interpreter Interpreter Interpreter Interpreter
Audio Amplicaon Audio Amplicaon Audio Amplicaon Audio Amplicaon Audio Amplicaon
Touch Screen Monitor Touch Screen Monitor Touch Screen Monitor Touch Screen Monitor Touch Screen Monitor
Communicaon Assistance
(Script)
Communicaon Assistance
(Script)
Communicaon Assistance
(Script)
Communicaon Assistance
(Script)
Communicaon Assistance
(Script)

Direcons Claried, Highlighng Tool, Headphones, Noise Buers, Redirect to the Test, Change Background Font & Colors, Magnicaon, Blank Paper, and General Masking
are available to all students.
Listening Device Listening Device Listening Device Listening Device Listening Device
Tacle Graphics Tacle Graphics Tacle Graphics Tacle Graphics Tacle Graphics
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
57/26/2018

   


Speech to Text Speech to Text Speech to Text Speech to Text
Word Processor Word Processor Word Processor Word Processor
Alternate Keyboard Alternate Keyboard Alternate Keyboard Alternate Keyboard
Communicaon Device Communicaon Device Communicaon Device Communicaon Device

Calculator
Manipulaves
Mulplicaon Chart
100s Chart
Number Line

Slant Board Slant Board Slant Board Slant Board
Word Predicon Word Predicon Word Predicon Word Predicon
Adapted Grips, Wring Tools Adapted Grips, Wring Tools Adapted Grips, Wring Tools Adapted Grips, Wring Tools
Answers Recorded Answers Recorded Answers Recorded Answers Recorded
Transferred Answers Transferred Answers Transferred Answers Transferred Answers

Extended Time Extended Time Extended Time Extended Time
Allow Breaks Allow Breaks Allow Breaks Allow Breaks

Specied Seang Specied Seang Specied Seang Specied Seang
Alternate Locaon Alternate Locaon Alternate Locaon Alternate Locaon
Individual Tesng Individual Tesng Individual Tesng Individual Tesng
Small Group Tesng Small Group Tesng Small Group Tesng Small Group Tesng

    


Speech to Text Speech to Text Speech to Text Speech to Text Speech to Text
Word Processor Word Processor Word Processor Word Processor Word Processor
Alternate Keyboard Alternate Keyboard Alternate Keyboard Alternate Keyboard Alternate Keyboard
Communicaon Device Communicaon Device Communicaon Device Communicaon Device Communicaon Device

Calculator Calculator
Manipulaves Manipulaves
Mulplicaon Chart Mulplicaon Chart
100s Chart 100s Chart
Number Line Number Line

Slant Board Slant Board Slant Board Slant Board Slant Board
Word Predicon Word Predicon Word Predicon Word Predicon Word Predicon
Adapted Grips, Wring Tools Adapted Grips, Wring Tools Adapted Grips, Wring Tools Adapted Grips, Wring Tools Adapted Grips, Wring Tools
Answers Recorded Answers Recorded Answers Recorded Answers Recorded Answers Recorded
Transferred Answers Transferred Answers Transferred Answers Transferred Answers Transferred Answers
Diconary (English III only)
Thesaurus (English III only)

Extended Time Extended Time Extended Time Extended Time Extended Time
Allow Breaks Allow Breaks Allow Breaks Allow Breaks Allow Breaks

Specied Seang Specied Seang Specied Seang Specied Seang Specied Seang
Alternate Locaon Alternate Locaon Alternate Locaon Alternate Locaon Alternate Locaon
Individual Tesng Individual Tesng Individual Tesng Individual Tesng Individual Tesng
Small Group Tesng Small Group Tesng Small Group Tesng Small Group Tesng Small Group Tesng
**Only available for students with a disability that severely limits or prevents the ability to perform basic math calculaons (i.e., student is
unable to perform single digit addion, subtracon, mulplicaon, or division) even aer varied and repeated aempts to teach the student to
do so. Refer to the LEAP 2025 Accommodaons and Accessibility Manual**


   
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
67/26/2018


   

If the student requires an accommodaon that is not listed as an opon above and does not change the construct being measured by a test, the
school may request approval for the use of the accommodaon on statewide tesng by subming the Unique Accommodaon Request Form.
• The accommodaon to be requested and the reason needed must be described in the space below.
• The accommodaon will only be approved by LDOE if used rounely in the classroom as documented here.



List instruconal services/intervenons. Documentaon is required.

(01) Parent programs or agency involvement suggested (Specify):
(02) Alert bus driver or other personnel (Specify):
(03) In-service school personnel involved with the student on the disability:
(04) Suggest interventions strategies for periods of transition (e.g., changing classes, PE, cafeteria et al) (Attach any additional information.):
(05) Other:
The listed accommodaons must be appropriate and must not subvert the purpose of the test or violate test security. Check with the District Secon
504 Coordinator, School Test Coordinator, and/or District Test Coordinator for the appropriateness of other accommodaons not listed above.

 English Spanish French Vietnamese Chinese Other:


 


 


 


 

**Signature oponal pursuant to LEA procedures. **Signature oponal pursuant to LEA procedures.
 must be documented on this form or on alternate form and maintained with condenal
records at all mes. Please aach alternate form that documents nocaon of parental rights (if applicable).



The LDOE does not discriminate on the basis of age, color, disability, naonal origin, race, religion, sex, sexual
orientaon, gender identy, polical aliaon, or genec informaon.
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SECTION 504 INDIVIDUAL ACCOMMODATION PLAN (IAP)

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Completed 25 March 2021

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