Fillable Section 504 Accommodation Plan* (USDA Food and Nutrition Service)

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Section 504 Accommodation Plan* (USDA Food and Nutrition Service)

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The Section 504 Accommodation Plan* (USDA Food and Nutrition Service) form is 5 pages long and contains:

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  • 19 check-boxes
  • 74 other fields

Country of origin: US
File type: PDF

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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 504Accommodations@strongschools.nyc?
Allergy or Seizure Plan
Health Director Approval
(If a funded service is authorized by your
Health Director.)
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Section 504 Accommodation Plan* (USDA Food and Nutrition Service)

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Completed 15 June 2022

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