Student Accommodation Refusal Form
Directions: If a student refuses an accommodation listed in his or her Individualized Education
Program (IEP), 504 plan, or if required by the Illinois State Board of Education, an EL plan, the
school should document in writing that the student refused the accommodation, and the
accommodation must be offered and remain available to the student during testing. This form
must be completed and placed in the student’s file and a copy sent to the parent on the day of
refusal. Principals (or designee) should work with Test Administrators to determine who, if any
others, should be informed when a student refuses an accommodation documented in an IEP, 504
plan or if required by the ISBE, an EL plan.
Date:
Student ID#:
Student Name:
Grade:
School Name:
School District:
IAR Assessment:
Test Administrator:
Accommodation(s)
refused: Reason for refusal:
Comments:
Student’s Signature (oponal): ________________________________________________________
Signature of Test Administrator: _______________________________________________________
Keep this form on le at the school.
A copy must be sent home to the parent.
click to sign
signature
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click to sign
signature
click to edit
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