Вы находитесь на странице: 1из 2

504 Student Accommodation Plan

Date written: Reviewed:


Student: District: Grade: 10th Grade

John Doe Bellefonte Area School District
Parent name(s): Plan facilitator: Date of birth: 8/13/00
Joe and Jill Doe Stacey Norfolk

Reason for meeting:

☒ Initial evaluation
☐ Review/update
☐ Discontinuation of 504 services

Sources of evaluation information (check each one used):

☒ Aptitude and/or achievement tests
☒ Teacher recommendations
☐ Adaptive behavior
☐ Other (specify):

School Attendance Data, Parent Input, and Doctor Diagnosis/Report

Brief background with area of suspected disability or disability noted:

John Doe was diagnosed with Leukemia early last month (November 2016). His symptoms include
being easily fatigues, increased susceptibility to illness and infection, coughing, shortness of breath
and bruising or bleeding easily. John is also dealing presently with stomach issues, lack of appetite,
and nauseous. He has begun chemotherapy and radiation therapy at this time, making all the
symptoms exacerbated and more frequent. John will be attending many doctors’ appointments and
requiring absences from school weekly.

Current academic functioning:

John’s teacher’s report he is behind in all his classes at this point in time due to his absences and the
inability to complete the large amount of school work from missing school. His teachers report he is at
risk to fail classes due to incomplete work and the amount of school work now due. When in class,
teachers report John is tired, placing his head down on the desk, taking breaks from school work, and
asking or needing to go to the nurse. Looking at his prior achievement tests, John has been found to
be proficient in Math, Science, and Language Arts in 8th grade. Prior to this point in time, John has
always been a responsible student, achieving Honor Roll or High Honor Roll. It is apparent from this
information that John’s academic achievement is suffering due to his medical condition.

Areas of strength:
Intelligent student achieving honor roll or above typically
Attentive and Motivated to complete work
Strong Parental Support
Continued Effort to complete work
Well liked by peers
Can work independently
Needs minimal instruction to grasp new concepts
Does the team believe that the student meets the criteria for provisions under the Section 504 and
the ADA?
☒ Yes
☐ No
If yes, complete the prompts below.

Check the major life activity interfering with academic success:

☐ Seeing
☐ Hearing
☐ Walking
☐ Learning
☐ Reading
☒ Thinking
☒ Concentration
☒ Sleeping
☒ Eating
☐ Bowel functions
☐ Bladder functions
☒ Digestive Functions

Or specify alternative of equivalent scope and importance:

Accommodations Person responsible

Assignments will be shorten, such as math homework, shorter General Education Teachers
essays, or changing style of tests, in the hope that his schoolwork
will be less time consuming

John will be granted extended time to complete and turn in General Education Teachers
schoolwork. Teachers should attempt to give assignments ahead
of time if an absence or appointment is forthcoming.

John’s class schedule shall be modified by placing all his major School Counselor
subject area classes in the afternoon, given the likelihood of
tardiness in the mornings.

Teachers will provide study guides, reviews, and detailed notes General Education Teachers
prior to any examination in the even the student has missed
material that was presented.

For this marking period and until reviewed by the team members, General Education Teachers/
John should be graded on a pass/fail standard. School Counselor