Fillable Section 504 Accommodation Plan*

Fill Online, Printable, Fillable, Blank Section 504 Accommodation Plan* Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Section 504 Accommodation Plan*

On average this form takes 22 minutes to complete

The Section 504 Accommodation Plan* form is 5 pages long and contains:

  • 0 signatures
  • 19 check-boxes
  • 81 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
2
s
School Year: _____________
School DBN and Name: _____________
Date of 504 Team Meeting: ______________________
Student Name
Disability/Diagnosis:
(from Medical Accommodations Request Form)
OSIS #:
Classroom/Homeroom Teacher:
Parent/Guardian Preferred Spoken Language:
Grade:
Home Address:
Paraprofessional (if applicable):
DOB:
Contact 1
Contact
Name:
:
Relationship to Student:
Relationship to Student:
Home Phone Number:
Home Phone Number:
Work Phone Number:
Work Phone Number:
Cell Phone Number:
Cell Phone Number:
Name
Section 504 Accommodation Plan*
*For students with diabetes who require accommodations, utilize the Section 504 Plan Diabetes Template.
This Plan will be reviewed as needed and before the end of each school year and, if necessary, amended at the
time of the review. Parent/guardian will inform the 504 Coordinator of any changes to the student’s disability at
any point during the school year that may require review of this Plan.
504 Coordinator will complete this Plan with 504 Team (including parent/guardian) input and based
upon relevant documentation (e.g., reports, evaluations or diagnoses provided by the student’s parent/
guardian, student’s grades, disciplinary referrals, health information, language surveys, parent/guardian
information, standardized test scores, and teacher comments).
Student & Family Information
Emergency Contact Detail
Emergency Contact Instructions: In the event of emergency, the student’s Plan and MAF (if relevant) will
remain in effect.
or
Name
Role
1.
504 Coordinat
2.
Parent/Guardian
3.
4.
5.
6.
☐ ACCESSIBLE SITE
☐ AIR CONDITIONING
☐ AMBULATION ASSISTANCE
☐ ASSISTIVE TECHNOLOGY
☐ CLASSROOM ACCOMMODATIONS
504 Team Information
Services & Accommodations
504 Coordinator enters all authorized Services & Accommodations, specifies the accommodations to be
provided (e.g.: Test Accommodations – smaller setting with no more than 12 students, extended time to 1.5, 5
minute break every 30 minutes), and marks any fields not applicable N/A.
Accommodation and Description of Accommodation
)
☐ HEALTH PARAPROFESSIONAL
☐ ELEVATOR PASS
☐ EPI-PEN
☐ RESTRICTED ACTIVITY
☐ SAFETY NET (High School only)
☐ TESTING ACCOMMODATIONS
☐ TRANSPORTATION (As approved by OPT. Consult with school’s Transportation Coordinator)
☐ OTHER - Please describe:
Accommodation and Description of Accommodation (Continued
Date
Date
_________________________________________
Accommodation DOE School Staff
Name
DOE Title Responsibilities (if not specified above)
1.
2.
3.
4.
5.
______________________________
______________________________
School Responsibilities
Indicate staff who will provide each accommodation
I have received the DOE Notice of Non-Discrimination under Section 504 and Notice of Eligibility. By
signing, I consent to the provision of accommodations to my child as written above.
Approved and received:
Parent/Guardian
Approved and received:
_________________________________________
School Administrator/504 Coordinator and Title
504 Accommodation Request Forms
Notice of Non-Discrimination under Section
504
Notice of Eligibility
Signed 504 Plan
504 Meeting Attendance Sheet
(if applicable)
Notes on Services Not Approved
Notes from 504 Coordinator
ASHR Form ID:
ADMINISTRATIVE USE ONLY
Supporting Documentation
Has the following documentation been submitted to
504Accomdations@strongschools.nyc?
Allergy or Seizure Plan
Health Director Approval
(If a funded service is authorized by your
Health Director.)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Section 504 Accommodation Plan*

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 1 June 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document