504 PROCEDURES MANUAL

Created July 2004© IDEAs in Education, LLC

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504 PROCEDURES MANUAL Section 504 of the Rehabilitation Act of 1973 is a federal law that prohibits discrimination against persons with disabilities in any program that receives federal financial assistance from the United States Department of Education. The ____ School District is a recipient of federal financial assistance from the Department of Education and, therefore, is covered by Section 504. Which students are covered?

Under 504, a person with a disability is defined as an individual who:

1. Has a mental or physical impairment that substantially limits one or more major life activities;

2. Has a record of such an impairment; or 3. Is regarded as having such an impairment. Students who satisfy the first definition are entitled to a free appropriate public education (“FAPE”) in the least restrictive environment and an individualized accommodation plan. FAPE, under Section 504, is defined as the provision of regular or special education and related services that are designed to meet the individual educational needs of the disabled student as adequately as the needs of nondisabled students.

Students who satisfy only the second and third definitions are not entitled to FAPE or accommodations, but are entitled to be free from discrimination.

Mental or physical impairments are broadly defined and include any diagnosed medical or

psychological condition. However, an impairment, alone, is insufficient to qualify a student as Section 504 disabled. In addition, a medical diagnosis or the fact that a student takes medication is not controlling in determining whether that student has a 504 disability. The Office of Civil Rights, which is charged with the responsibility to enforce 504, has stated that finding a student 504 eligible solely on the basis of a diagnosis generally violated Section 504.

A student’s eligibility under Section 504 is not determined by a doctor or psychologist but by

a multidisciplinary team convened by the District. That team must include persons who are knowledgeable about the student, Section 504, and the evaluation data to be considered.

Major life activities, as defined by Section 504, include – but are not limited to – activities such as walking, seeing, hearing, speaking, breathing, learning, working, caring for one’s self and performing manual tasks. When interpreting this provision of 504, courts have taken a global view and stated that the activity should be viewed as central to daily living. The United States Supreme Court has stated that, to be substantially limited, the impairment’s impact must be permanent or long term. Other courts have defined substantial as limited considerably or to a large degree. Minor or moderate limitations are not sufficient for a student to be eligible under 504. In determining whether a student’s impairment substantially limits a major life activity, the District is required to compare the individual to his or her average peer in the population. Students, therefore, are measured by reference to the performance of children at the same age or grade level. Under Section 504, it is not proper to compare the student to only his own potential.


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When determining eligibility under Section 504, the District also is required to determine if environmental, cultural, or economic disadvantage are the primary reason for any limitations that the student may exhibit. Temporary impairments may be covered by 504 if the impairment is substantially limiting and if it is of sufficient duration. However, temporary, non-chronic impairments of short-duration, with little or no permanent long-term impact, usually are not disabilities as defined by Section 504. Child Find and Evaluation: School districts that receive federal financial assistance have the responsibility to identify and evaluate a student to determine if that student is eligible under Section 504. Students who are suspected of having a 504 disability can be referred for evaluation by a parent or by members of the District’s certified staff. A copy of the 504 referral form can be obtained from ________. Before identifying a student as 504 eligible, the District is required to conduct an evaluation of that student to determine if he/she satisfies the first definition above. That evaluation can consist of a review of existing data or formal assessment or a combination of the two. A formal medical or psychological diagnosis, standing alone, is insufficient to qualify a student as 504 eligible. Parents and/or legal guardians may be asked to provide written consent to obtain further information from diagnosing professionals. Such outside information must be considered by members of the multidisciplinary team convened to consider eligibility. However, outside information from medical professionals is not determinative in deciding whether a student is disabled. If the District’s multidisciplinary team believes that a current medical assessment or evaluation of the student is necessary to determine the existence of an impairment or as part of the evaluation to determine 504 eligibility, that evaluation must be provided at no cost to the parent. If the multidisciplinary team determines that a formalized initial assessment is necessary, informed and written parental consent must be obtained. No consent is necessary to conduct a review of existing data or to conduct observations The parent of a student who is seeking 504 eligibility must permit the District to conduct an evaluation with assessments to determine if the student has a disability. If the parent refuses to consent to an evaluation, the student will not be considered to be disabled. The District has the right to use the due process procedures identified in the procedural safeguards if the parent refuses to consent to a 504 evaluation, but the District is not required to do so. A District is not required to evaluate or identify a student as 504 disabled simply at a parent’s request if the District does not have reason to suspect that the student has a 504 disability. If a parent requests 504 eligibility and the District refuses that request because it has no reason to suspect a disability, the District will provide the parent with a written notice of refusal and a copy of the District 504 procedural safeguards. There is no automatic obligation to evaluate students for 504 eligibility after the determination that a student is not eligible under the Individuals with Disabilities Education Act. Students deemed eligible under 504 must also be periodically reevaluated. Reevaluations can consist of a review of existing data, observation or a formal assessment. Parents must be notified by the District of an intent to reevaluate under 504, but parental consent is not necessary for periodic reevaluations. The District must reevaluate students before discontinuing a student’s eligibility under Section 504. That reevaluation can consist of a review of existing data or a formal assessment.


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Accommodation Plans: After a multidisciplinary team determines that a student is 504 disabled, a multidisciplinary team that may be the same or a different group of persons will convene, within a reasonable time, to develop an individualized accommodation plan for the student in order to provide FAPE. In general, a reasonable time is considered to be within 30 school days of the date that eligibility is first determined. The student’s parents are not required participants in that process, but the District will extend an invitation to the parent to participate and will attempt to schedule such meetings at a mutually convenient time. The team can meet without the parent’s participation. Discipline of Section 504 Disabled Students: Under Section 504, a disciplinary removal from a student’s placement for more than 10 days constitutes a change of placement and requires that certain procedures be followed. When a student is suspended, out of school, for more than 10 consecutive days or when a student’s short-term removals constitute a pattern of exclusion as currently defined by the Individuals with Disabilities Education Act (“IDEA”), the District will, within 10 school days, convene a multidisciplinary team to determine if the student’s act of misconduct is related to his or her disability. The multidisciplinary team will apply the IDEA manifestation standard that is in place at that time. The parent will be invited to attend but is not a required participant. If the team concludes that the student’s misconduct is related to his or her disability, the District will not impose a long-term suspension or removal (over 10 school days). If the team concludes that the student’s misconduct is unrelated to his or her disability, the District’s administrators will determine the appropriate discipline including, but not limited to, a long-term suspension or expulsion. During the period of disciplinary removal, the District will not provide any educational services to the student unless it provides such services to its regular education students in similar circumstances. A student is not considered to be disabled if he or she is currently engaged in the illegal use of drugs when the District is acting on the basis of that use. Therefore, when a student who has been determined to be 504 disabled is being disciplined for the currently illegal use of drugs (including alcohol), that student will lose his or her 504 protection and will be disciplined as if he or she was a regular education student and no manifestation determination will be held.

504 PROCEDURES 1. Student may be referred by a parent, teacher, administrator or Teacher Support Team. The

District will accept verbal or written referrals. Within five school days of a referral, the District will provide a copy of “Section 504 Referral Form” (Form A) to that person for completion as soon as possible.

2. If parent is the referring party, the District will send, in addition to Form A, a copy of “Parent

Referral Response Letter” (Form B) and the Section 504 procedural safeguards to the parent. 3. If a District employee is the referring party, the District will send the parent a copy of “504

Parent Letter Upon Staff Referral” (Form C) within five school days of receipt of the referral as well as a copy of the District’s 504 procedural safeguards.

4. a. Within 30 school days of a parent or District referral, the District’s 504

multidisciplinary team will convene to consider the referral and to review any existing data on the student. The multidisciplinary team for a particular student should be comprised of the District’s 504 Coordinator, the student’s teacher(s) and other individuals who are


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knowledgeable about the student and existing data. The parents are not mandatory participants, but should be invited to the meeting. Form D – Notification of 504 meeting – should be used to invite the parent and other participants.

b. At this meeting, if the team determines that existing data demonstrates that the student

(1) does not have a 504 disability or (2) is suspected of having an IDEA disability, the team should complete Forms F and G and provide those to the parent along with a copy of the procedural safeguards.

c. At this meeting, the team should determine whether the existing data is sufficient to

support the existence of a 504 disability and/or whether an evaluation is needed. In addition to reviewing the information included in Form A, the team should attach to Form A any additional information that is gathered or provided. Students who need only routine District accommodations to be successful educationally should not be considered for a 504 Plan. If the team determines that existing data is sufficient to support the existence of a disability, the team should complete Form E “504 Eligibility Determination Form.” A copy of Form E should be provided to the parent along with a second copy of the District’s 504 procedural safeguards. The team also should provide a copy of “504 Response to Referral Notification” (Form F) to the parent with the appropriate action checked as well as a copy of “504 Notice of Action” (Form G).

d. If the team determines that a formal evaluation is necessary to determine eligibility, the team should complete a written evaluation plan. The District should request the parent’s written consent for that evaluation by using Form H, “504 Consent for Initial Evaluation.” The District should also complete Forms F and G and provide those to the parent along with the procedural safeguards.

The District will complete the evaluation and convene the team to determine eligibility within 60 calendar days of receiving the parent’s written consent to evaluate. At that meeting, the team will complete Form E (Eligibility Determination Documentation). In addition, if necessary and appropriate, the team will prepare a written evaluation report of the assessments to be attached to Form E.

If the student is determined eligible, the team should also should complete Forms F

and G and provide copies of those to the parent along with Form E and the procedural safeguards.

5. Within 30 days after a determination of Section 504 eligibility, a 504 multidisciplinary team

will be convened to prepare an Individualized Accommodation Plan for the student. The parents will be invited to participate in accommodation plan meetings, but are not required participants. If appropriate, the student may also be invited. The team should consider all sections of Form I and determine what accommodations are necessary for the student to receive FAPE as defined above. The team, as part of this process, should consider whether the student needs accommodations for state or district-wide testing to receive FAPE as defined above. If the team determines that such accommodations are necessary, those accommodations should be included in the IAP. However, the team should also consider whether the type of testing accommodations being considered will impact test validity or will give the student an undue advantage.

For a particular student, the team may also need to consider whether the student

requires related services to receive FAPE. If so, those related services, including the


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frequency and duration, should also be written into the IAP. Transportation may need to be considered, particularly if the team places the student

in a program not operated by the District. In those situations, the District must ensure that adequate transportation to and from those services is provided at no greater cost than would be incurred by parents if the student was placed in the District’s programs.

If the team refuses a request from a parent with respect to the provision of FAPE

during the IAP process, the parent should be provided with a notice of action (Form G) refusing the request and stating the reason for that refusal.

Copies of the completed Plan (Form I) should be provided to all teachers and/or staff

with implementation responsibilities. The District should also provide a copy of the plan to the parent. The team should determine which District employee is responsible for monitoring implementation of the plan. The case manager is responsible for informing each staff member of his or her implementation responsibilities.

In general, the multidisciplinary team should anticipate at least an annual review of

each accommodation plan. The team can meet more frequently if necessary to review and, if necessary, revise the plan. The designated case manager is responsible for convening the team annually and for responding to staff or parent requests to convene more frequently.

Students with disabilities are entitled to an equal opportunity to participate in

nonacademic and extracurricular services. However, the Office of Civil Rights has stated that such opportunities are not included within the definition of FAPE but instead are included with the law’s discrimination prohibition. Since the IAP is written to address FAPE issues, the team does not need to include within the IAP any accommodations that the student will need for this equal opportunity to participate. Parents and eligible students should be informed that those nondiscrimination issues may be addressed with the District’s Section 504 Coordinator.

6. Each 504 student will have a designated case manager who will have the responsibility to

ensure the completion of all necessary paperwork and who will serve as the primary contact person with the parent and student. The case manager also will be responsible to convene the team whenever necessary, to extend invitations to the parent to attend such meetings, and to determine when a reevaluation is necessary.

7. Transfer Procedures:

a. Out-of-District transfers: Students with an existing 504 plan who transfer to the ____ School District from another school district. Within five days of enrollment, the District will request records from the sending school district, including copies of any 504 evaluations, eligibility determinations and accommodation plans. The building 504 coordinator, upon receipt of such records, will determine whether to accept the evaluation and 504 status and accommodation plan. If the building 504 coordinator determines that the eligibility determination might be incorrect, the coordinator will convene a 504 multidisciplinary team to discuss a reevaluation of the student. If the building 504 coordinator determines that the accommodation plan needs to be reviewed, the coordinator also will reconvene the 504 multidisciplinary team for that student. The parents will be invited to attend any such meetings, but are not required participants.


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b. Building-to-Building Transfers: Before the end of each school year, each building 504 coordinator is responsible to communicate with the 504 building coordinators of other buildings to discuss those students who will be transferring within the District and to determine whether a reevaluation is necessary and/ or whether the student’s accommodation plan needs to be revised to address the changing educational environment. If so, the student’s multidisciplinary team should be convened to address reevaluation and/or a revised plan. The parents will be invited to any such meetings, but are not required participants

8. Removal of Eligibility: When the team suspects that a 504 eligible student may not have a current substantially limiting impairment, the case manager is responsible for convening the team to discuss a review of existing data/reevaluation to determine continued eligibility. The parent will be invited to such meetings but is not a required participant. If the team concludes, after a review of existing data or formal assessment, that the student no longer is eligible, the team will prepare an evaluation report that reflects that decision and will provide the parent with a properly complete Form G (notice of action) and a copy of the procedural safeguards.

9. Discipline Procedures: In general, most 504 students should be expected to follow the

District’s disciplinary policies, rules, regulations and procedures and this should be noted on the Accommodation Plan. When determining a student’s 504 eligibility, the multidisciplinary team should consider whether the impairment that is substantially limiting has a direct impact on a student’s behavior and, if so, the team may consider conducting a functional behavioral assessment as part of the student’s evaluation. If the team concludes that the impairment has a direct and substantial relationship to the student’s behavior, the team should address the behavior through the Accommodation Plan and should consider whether a behavior plan is necessary for the student to have an equal opportunity to participate.

For suspensions of greater than 10 consecutive days or those cumulative short-term

suspensions that constitute a pattern of exclusion as defined by the IDEA, the team will convene to conduct a manifestation determination within 10 school days of the date of the decision to change the student’s placement through a disciplinary removal. The parent will be invited to participate but is not a required participant. The team should complete Form J – Manifestation Determination Form.

If the team determines that there is no relationship between the disability and the behavior,

the student will be treated the same as nondisabled students and can be suspended or expelled according to the District’s Code of Conduct and the level of the offense. No services will be required or provided in this situation unless the District provides such services to its nondisabled students in the same circumstances.

If the team determines that there is a relationship between the disability and the behavior, the

student can be suspended for up to 10 consecutive days with no educational services or for any days that are less than a pattern of exclusion. If deemed necessary, the team may need to convene to determine if a change of educational placement may be needed or if the student should be referred under IDEA.

A student who is otherwise eligible under 504 but is currently engaged in the illegal use of

drugs or alcohol and who is being disciplined for such use will lose his or her protection as an eligible student and will not be entitled to a manifestation determination and will be disciplined as if he or she were a nondisabled student.


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Form A SECTION 504 REFERRAL FORM

Name of Student:_____________________________________ Date of Birth:____________ School ______________________________________________ Grade:__________________ Person Making Referral:__________________________ Position/Relationship:___________ Date of Referral:_________________________________ In the _______ School District, the teacher support team will act on a 504 referral within 30 school days of the date of the referral. Reason for Referral: Note: – a disability exists under 504 only if the student currently has a mental or physical impairment that substantially limits one or more major life activities. Impairment or Suspected Impairment:________________________________________ Major Life Activities Impacted: _____________________________________________ (Examples: hearing, seeing, communication, learning, taking care of one’s self, manual task performance, walking, speaking, breathing). Describe Impact of Impairment on the Major Life Activities Listed;_________________ Attendance: Days Present___________________ Days Absent ___________________ List reasons for absences: ________________________________________________________ Medical: Are you aware of any medical conditions or diagnoses? ( If yes, please list) To your knowledge, is the student on any medication? ____ Yes ___ No Describe: Impact of the medication on student:____________________________________ Does the student wear glasses or other corrective lenses? ___ Yes ___ No Does the student wear an assistive hearing device? ___ Yes ___ No Are you aware of any other mitigating measures that impact the student educationally? (e.g., glasses, medication, hearing aides). If yes, please list and describe the impact of all mitigating measures.


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Existing Testing Data: List or attach a copy of the student’s State or District-wide testing data or the results of any evaluations previously administered for IDEA or 504. Current Grades: Promotion/Retention: Has the student ever been retained? ___Yes ___ No ESL: Is this student considered to be bilingual or is English the student’s second language? ____ Yes ____ No Academic Characteristics: Please estimate the student’s current grade levels in the following academic areas and state the basis for that estimate.

_____ Reading Fluency _____ Spelling

_____ Reading Comprehension _____ Math Calculation

_____ Basic Reading Skills _____ Math Reasoning _____ Written Expression

Alternative Strategies in Regular Education: List any routine educational modifications or alternative strategies that have been used with this student and indicate on a scale of 1 to 3 (with 1 being of no assistance and 3 being of great help) whether the modifications or strategies assisted the student to be successful in regular education. _____ Modified instructional methods (list) 1 2 3 _____ Modified instructional pacing 1 2 3 _____ Modified instructional materials 1 2 3 _____ Reteaching 1 2 3 _____ Parent conferences 1 2 3 _____ Behavior contract or plan 1 2 3 _____ Other (list) 1 2 3 List any alternative programs in which the student has participated: _____ ESL _____ Remedial English


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_____ Title I Reading _____ Remedial Math _____ RTI _____ Remedial Writing _____ Gifted _____ Vocational _____ Tutoring _____ Alternative School

_____ Summer School _____ Other (List) Please describe the results of these programs for this student: Teacher Referrals Only: Based on your knowledge and observation of this student, please rate this student’s performance in comparison with the average student in the classroom. Observations 1-Unsatisfactory to 5-Exellent Classroom Work

1 2 3 4 5

Homework

1 2 3 4 5

Tests

1 2 3 4 5

Reading Performance

1 2 3 4 5

Math Performance

1 2 3 4 5

Written Expression

1 2 3 4 5

Spelling

1 2 3 4 5

Following Oral Directions

1 2 3 4 5

Following Written Directions

1 2 3 4 5

Attendance

1 2 3 4 5

Attention Span

1 2 3 4 5

Organization Skills

1 2 3 4 5

Behavior/Compliance

1 2 3 4 5

Work Completion

1 2 3 4 5


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Check any behavioral characteristics that this student generally displays that might adversely impact the student’s learning. ____ Shy ____ Irritable _____ Moody ____ Requires Constant ____ Anxious _____ Disruptive Encouragement ____ Rejected by Peers ____ Distractible _____ Daydreams ____ Argumentative ____ Aggressive _____ Withdrawn/Depressed Discipline: Attach a copy of the student’s discipline referrals or records for the past two years. Are you aware of any cultural, economic, or environmental factors that impact the student educationally? (Please list all). Are there any lack of instruction issues, including home schooling, of which the teacher is aware? Date Referral Received:___________________________________________ Name of Person Receiving:________________________________________ Teacher Support Team Action: ______ IDEA Disability Suspected; Refer to Special Education Department

______ 504 Disability Suspected; Evaluation Needed ______ 504 Disability Suspected; Existing Data

Sufficient to Make Eligibility Determination ______ No Evaluation Needed – No Disability Suspected ______ Additional Alternative Strategies Recommended Before Evaluation Pursued Date of TST Action: _______________ TST Participants: ______________________________________________________________________________ ______________________________________________________________________________


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Form B Parent Referral Response Letter

[Date] [Parent/Guardian Name and Address] Re: [child’s name] Dear : This letter is to acknowledge receipt of your referral of your son/daughter for consideration of

504 eligibility. Section 504 is a federal law that provides for certain protections as well as

individualized accommodation plans for students who are determined to be disabled under that law.

Under 504, a student is disabled if he or she has a mental or physical impairment that substantially

limits a major life activity.

The District’s procedures require that a Teacher Support Team review your referral by

gathering existing data regarding your child and determine if an evaluation of your

child is necessary to decide if your child is eligible under 504. I am enclosing a copy of the District’s

Section 504 referral form. Please complete this form as soon as possible. The Teacher Support

Team will review the information you provide as well as information from other sources and you will

be notified within 30 school days of the TST team’s decision.

I also am enclosing a copy of the District’s 504 procedural safeguards for parents. If you

have any questions, please feel free to call me at _________.

_______________________________________ 504 Coordinator Encl. 504 Parent Safeguards 504 Referral Form


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Form C 504 Parent Letter Upon Staff Referral

[Date] [Parent/Guardian Name and Address] Re: [child’s name] Dear : This letter is to make you aware that a member or members of the teaching staff have referred

your child for possible consideration of eligibility under Section 504. Section 504 is a federal law

that provides for certain protections as well as individualized accommodation plans for students who

are determined to be disabled under that law. Under 504, a student is disabled if he or she has a

mental or physical impairment that substantially limits a major life activity.

As a result of the referral, the District’s Teacher Support Team is in the process of gathering

information about your child. If you would like to provide additional information regarding your

child, please send it to my attention. The Teacher Support Team will be deciding whether an

evaluation of your son/daughter is necessary to determine his or her eligibility under Section 504. At

some point, the District may invite you to attend a conference to discuss the possibility of an

evaluation.

I also am enclosing a copy of the District’s 504 procedural safeguards for parents. If you

have any questions, please feel free to call me at _________.

_______________________________________ Teacher Support Team Encl. 504 Parent Safeguards


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FORM D 504 MEETING NOTIFICATION

Date:_________________________________ To:___________________________________ Parent/Legal Guardian Adult Student (age 18+ or emancipated minor) This notification is to [inform you/confirm with you] that a meeting with you has been scheduled for _______________ at _____________ at ________________________________. (Date) (Time) (Location) The purpose of this meeting is to: (check all that apply) Review existing data as part of an Conduct Manifestation Determination initial evaluation or 504 reevaluation Consider continued 504 eligibility Determine initial 504 eligibility Develop initial 504 accommodation plan Review/revise 504 accommodation plan Other:___________________________ The following individuals have been invited to participate in the meeting: Name: Role: ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ ___________________________________ ____________________________________ If you are unable to attend this meeting, please contact me at __________ as soon as possible. _____________________________ _______________ _________________ Name Title Date


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FORM F

504 RESPONSE TO REFERRAL NOTIFICATION Date:______________________________________ Student’s Name:_____________________________ DOB:_________________ Grade:______________ Dear___________________________: As you know, the District’s Teacher Support Team has been considering □ a parent 504 referral or □ a staff 504 referral of your child for purposes of Section 504. The TST has reviewed existing information regarding your student to determine if there is reason to suspect that your child may have a 504 disability. A. The TST has reviewed the following information regarding your child: ___ parent/guardian reports ___ educational history ___ alternative intervention strategies ___ medical records/reports ___ private evaluations ___ discipline records Other:_______________________________________________________________ B. Based on the referral and the review of existing information regarding your child, the TST has considered the following options and determined that the indicated actions were warranted. ___ Continuation of regular education with no routine accommodations necessary ___ Continuation of regular education with routine accommodations proven effective ___ Continuation of regular education with new routine accommodations

___ Existing data is sufficient to make 504 eligibility determination; Schedule team meeting to review existing data to determine 504 eligibility

___ Team meeting to discuss the need for formal evaluation/assessment prior to determining 504 eligibility ___ Existing data does not support the suspicion or existence of a 504 disability and no evaluation will be conducted ___ Suspicion of an IDEA disability; Referral to special education team for possible IDEA evaluation If you have any questions or concerns about the above-listed action, please contact the TST person listed below or the District’s 504 Coordinator at [list phone number]. If you are in disagreement with this action, you have the right to appeal the decision as indicated in the 504 procedural safeguards previously provided to you. __________________________________________________ ______________________ TST Chairperson Phone


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FORM G 504 NOTICE OF ACTION

Student’s Name:_______________________________ Grade:______________________ Parent/Guardian Name and Address:______________________________________________ Date Notice Provided:__________________________ Method of Provision: □ Mailed – First Class Mail □ Mailed – Certified Mail □ Hand Delivered to Parent/Guardian Under Section 504 of the Rehabilitation Act of 1973, the District is required to provide you with written notice regarding changes in or refusals relating to the identification, evaluation, or educational placement of your child. The following is to describe the action(s) being □ Proposed or □ Refused by the District. □ Initial Evaluation □ Change of Placement □ Ineligibility for Services □ Removal of Eligibility □ Reevaluation □ Other:_________________________ Explanation of Action: Basis for the Action: You previously have been provided with a copy of your 504 Procedural Safeguards. If you would like an additional copy or an explanation of those safeguards, please contact____________________. If you have any questions regarding this Notice, you may contact me at the following number:__________________. ____________________________ ____________________ Name Title


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Review of Existing Data Documentation Form

Student’s Name: School District: ________________________________________ Date of Birth: ____________________ Age: Grade:

This data review is being conducted as part of:

A 504 Referral______________________ Teacher Support Team members and other qualified professional, as appropriate

met conferred

to review all relevant existing evaluation information in order to determine what additional data, if any, was needed to determine:

1. Whether the child has a particular category of disability or, in case of a reevaluation, whether the child continues to have a disability.

2. The present levels of performance and educational needs of the student. 3. Whether the child needs a 504 Accommodations Plan or in the case of a reevaluation, whether the child

continues to need of an accommodation plan.

In making this determination, the following information was reviewed by the team: (Note: Not all areas will have all data sources addressed)

AREA/ DATA SOURCE DESCRIPTION OF DATA REVIEWED

SUMMARY OF INFORMATION GAINED

Vision General screening

School health records

Previous assessments

Medical reports

Teacher

Parent

Other Further Assessment Information Needed? Yes No

Assessment instruments, if known

Hearing General screening



Medical reports

Teacher

Parent



Health/Motor General screening


Medical reports



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Teacher

Parent



Speech/language

General screening


Medical reports

Teacher

Parent

Related service provider



Intellectual/Cognitive Previous assessments

Medical reports

School records

Teacher

Parent



Adaptive Behaviors Previous assessments

Medical reports

School records

Teacher

Parent



Social/Emotional/Behavioral


Medical reports

Teacher

Parent

Student

Counselor

Related service provider

Outside agency


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School records



Academic Achievement Classroom/teacher assessments

Curriculum-based assessments

Agency/district-wide assessments

State-wide MAP assessments


School records

Teacher

Parent

Student

Intervention strategies

Current progress report



Other

Assistive Technology Previous Assessments

Medical Reports

Teacher

Parent

Student

Related Service Provider

Outside agency




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The TST members completed this review of existing data on _____________________ (m/d/y).

Names Title/Role

__________________________________________ Parent

__________________________________________ LEA 504 Coordinator or Designee

__________________________________________ Regular Education Teacher

__________________________________________ School Counselor

__________________________________________ Others (indicate role)

__________________________________________ _________________________________

__________________________________________ _________________________________


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504 CONSENT FOR INITIAL EVALUATION

Parental consent for Initial Formal Assesement Under Section 504 Student:_________________________________ DOB:_______________________ School:__________________________________ Grade:_______________________ I/We, the parent(s)/guardian of ________________________________, give written consent for the __________________________ School District to conduct an individualized initial evaluation of our child as indicated in the Evaluation Plan developed by the District’s multidisciplinary team. I/We were invited to participate in the development of that Plan. I/ We have received a copy of that evaluation plan and understand that it describes the areas in which the District wishes to assess and the possible test instruments to be used. I/We understand that the District will complete the assessment within sixty (60) days of my/our consent unless reasonable cause exists to extend that timeline. I/We understand that the purpose of this assessment is to gain further information about our child and his/her possible eligibility under 504 and that, by refusing consent for this assessment, we would not be depriving our child of the right to attend public school. I/We also understand that we can ask any questions or address any concerns we might have with respect to this evaluation with appropriate staff prior to making a decision to consent or object to the assessment. I/We previously have been provided with a copy of our 504 procedural safeguards and have had an opportunity to read those safeguards. ____ I/We give my/our consent to the proposed initial evaluation. ____ I/We refuse to consent to the proposed initial evaluation. ____________________________________________ ___________________________ Signature of Parent/Guardian/Eligible Student Date


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Description of Areas to be Assessed and Known Tests to be Used DOCUMENTATION FORM

Vision Measures a student’s near/far point visual acuity, eye muscle control, depth perception, color blindness, orientation/mobility skills.

Professional evaluation by a qualified optometrist/ophthalmologist Telebinocular Other (specify):

Hearing Measures a student’s hearing acuity for pure-tones and speech, middle ear function, central auditory processing skills, and the need for/use of amplification systems

Professional evaluation by qualified medical personnel Audiometer Other (specify):

Health/Motor Measures a student’s physiological and neurological condition including gross and fine motor skills, metabolic functioning, and/or evidence of disease or injury. Assessment may also include laterality, directionality, balance, kinesthetic skills, tactile skills, and ambulatory/postural problems.

VMI Developmental Test of Visual Motor Integration Professional evaluation by: Physical Therapist

Occupational Therapist Other (specify):

Speech/ Language

Measures a student’s articulation skill, auditory perception, voice, fluency, receptive/expressive language development.

Speech: Informal Speech Sample/Oral Peripheral Exam Arizona Articulation Proficiency Scale (AAPS) – 3 Goldman-Fristoe Test of Articulation Other (specify):_____________________________________________________

Language: Informal Language Sampling Clinical Assessment of Spoken Language (CASL) Expressive One-Word Picture Vocabulary Tests (EOWPVT) Receptive One-Word Picture Vocabulary (ROWPVT) Oral & Written Language Scales (OWLS) Preschool Language Scale (PLS-3) Other (specify):

Intellectual/ Cognitive

Measures a student’s general mental abilities including specific strengths and weaknesses, and sensory perceptual learning processes.

Wechsler Intelligence Scales (WPPSI-R, WISC-III, WAIS-3, WASI, WISC-IV) Stanford-Binet Intelligence Scale Leiter Other (specify):

Adaptive Behavior

Measures a student’s ability to function and maintain self independently, and the degree to which the student meets satisfactorily the culturally imposed demands of personal and social responsibility

Vineland Adaptive Behavior Scale Adaptive Behavior Evaluation Scale (ABES) Other (specify):

Social/ Emotional/ Behavioral

Measures a student’s social/emotional/behavioral development in relation to learning interpersonal relationships, and self.

Behavior Evaluation Scale (BES, BES-II) Other (specify):

Academic Achievement

Measures a student’s educational skills and achievement levels Wechsler Individual Achievement Test Woodcock-Johnson Psycho-Educational Battery Part II Pre-Academic skills assessment battery of tests Diagnostic Teaching Other (specify):

Assistive Technology

Assesses a student’s need for assistive devices/services in order to maintain, increase, or improve the function capabilities of the student.

Other (specify):

Consent is granted for the Area to be assessed no the specific instrument(s) indicated. Tests may be added or substituted without further consent.

Consent is granted for the Area(s) to be assessed not the specific instrument(s) indicated. Tests may be added or substituted without further consent.

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SECTION 504 ELIGIBILITY DETERMINATION DOCUMENTATION FORM E

Student:____________________________________ DOB:_______________________ School/Grade:_______________________________ Case Manager:________________ Date of Section 504 Eligibility Determination Meeting:________________________________ I. State the Student’s MENTAL OR PHYSICAL impairments:____________________ ______________________________________________________________________ Diagnosed by:_________________________________ Date:_____________________ (A formal diagnosis is not required for consideration for eligibility). II. State the MAJOR LIFE ACTIVITIES impacted by the impairment(s): ___ Caring for one’s self ___ Performing manual tasks ___ Walking ___ Seeing ___ Speaking ___ Breathing ___ Learning ___ Hearing ___ Seeing ___ Other ___ None III. What, if any MITIGATING MEASURES are in place that limit the impact of the identified

impairments on the selected major life activities: ___ Glasses/contacts ___ Medication ___ Hearing aides/cochlear implant ___ Prosthetic Devise ___ Other Describe the impact of any mitigating measure: IV. SUBSTANTIAL LIMITATION

Describe whether and how the impairment substantially limits the major life activities indicated. In describing the limitation(s), the team should consider the child with any mitigating measure in place if that is how the student generally attends school. In addition, in making this determination, the student should be compared to the average student of same age/grade in the population.

Please also place on “X” on the following scale to indicate the degree that the impairment limits the

major life activity using the same guidelines as indicated above. 5----------------------------------Extremely ------------ 4----------------------------------Substantially ------------ 3----------------------------------Moderately ------------ 2----------------------------------Mildly ------------ 1----------------------------------Negligibly/None


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Is the substantial limitation on the major life activity that is described above primarily the result of cultural, economic, or environmental factors rather than the student’s physical or mental impairment? ___ Yes ___ No. If Yes, please describe and explain._______________________

If the limitation is primarily the result of cultural, economic or environmental factors, the student is not 504 disabled and an accommodation plan should not be developed. IV. Describe the existing data or evaluation information that supports the determination made in Section

III above. If the team’s determination in Section III above is less than “4”, the student is not eligible under

Section 504. If the determination of “4” or more and the substantial limitation is not primarily the result of cultural, economic or environmental factors, the team should proceed to prepare an Individual Accommodation Plan for the Student.

V. ELIGIBILITY DETERMINATION ____ Student is eligible under Section 504. ____ Student is not eligible under Section 504. VI. Eligibility Team Participants (Please list all) Name Position/Title ___________________________________________________ ________________________ ___________________________________________________ ________________________ ___________________________________________________ ________________________ ___________________________________________________ ________________________ ___________________________________________________ ________________________ Copy of form provided to parent on:________________________________________________ Method of delivery:_____________________________________________________________

Parent/Guardian Documentation I/We have reviewed this eligibility determination. I/We previously were provided with a copy of our 504 procedural rights and have had an opportunity to review those rights. ________________________________________________________ __________________ Signature of Parent/Guardian Date _____ Parent not in attendance, Section 504 determination and rights sent on ___________.


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FORM I 504 INDIVIDUAL ACCOMMODATION PLAN

Name:________________________________________ DOB:_______________________ Grade:________ School:______________________ Date of Meeting:______________ I. Describe the student’s impairment and how the student’s impairment substantially limits a

major life activity. II. Summarize the existing and/or evaluation data that supported the determination of 504

eligibility. III. Accommodations deemed necessary by the team for the provision of FAPE: Student Needs Related Interventions Location Responsible Implementation Evaluation To Impairment /Accommodations Person Dates IV. Educational Placement/LRE: V. Related Services: VI. Anticipated Review Date:


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VII. Participants (Name and Title): ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ ________________________________ _______________________________ I, the parent/legal guardian of the student named above, was given the opportunity to

participate in the development of this 504 Accommodation Plan and agree with the plan as developed. I also have been given a copy of my 504 Procedural Safeguards and have had the opportunity to review those safeguards.

_________________________________________ Parent/Guardian signature __________________________________________ Date Copy of 504 plan given to parent on ___________________________


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SAMPLE 504 ACCOMMODATION/MODIFICATION LIST Specific preferential seating Seat student near teacher Seat student in area free from distraction Seat student in area free from sound Seat student in area free from visual distraction Allow student additional break of rest time Ensure proper lighting Ensure proper desk height and seating comfort Arrange classroom to ensure physical accessibility Provide modifications to instructional equipment Encourage teacher to move around classroom to ensure proximity control Ensure that materials and supplies do not result in allergic reactions Peer Tutoring Peer Buddies Provide notetakers Use advance organizers Study guides Tape recorder Multi-sensory instructional materials Computers Simple directions Provide short-term feedback Reinforcement Break long assignments into multiple short assignments Flexible grading Shortened assignments Extended time for completion Low vocabulary/high interest materials


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Teacher Acknowledgement of Receipt: This student’s 504 plan and my responsibilities for implementation have been shared and explained to me. Teacher Name/Signature: Subject Taught: Date: ____________________________ ____________________________ ________________ ____________________________ ____________________________ ________________ ____________________________ ____________________________ ________________ ____________________________ ____________________________ ________________


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FORM J SECTION 504 MANIFESTATION DETERMINATION

Student Name:_____________________________________________ DOB:____________ Case Manger:______________________________________________ Date:____________ 1. 504 Impairment__________________________________________________________ 2. Summary of History to include: academic history, 504 Accommodation Plan, results of past

evaluations, information from outside sources (if appropriate), and information from parents._________________________________________________________________

_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 3. Summary of current misconduct/discipline decision: _______________________________________________________________________ ______________________________________________________________________ 4. Is student’s behavior a direct and substantial result of his or her disability: ____ Yes ____ No Explain rationale for decision:_______________________________________________ _______________________________________________________________________ 5. Recommendations from 504 Team: _______________________________________________________________________ List of Participants:


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504 PROCEDURAL SAFEGUARDS The main purpose of Section 504 of the Rehabilitation Act of 1973 is to prevent discrimination on the basis of disability. To that end, Section 504 of the Act provides, in pertinent part, as follows:

No otherwise qualified individual with a disability in the United States . . . shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance. . . .

An eligible student under Section 504 is a student who currently has a physical or mental impairment that substantially limits one or more major life activities. The following is a description of the rights granted by federal law to students with 504 disabilities and/or their parents or legal guardians and to those students who are suspected of having a 504 disability and/or their parents or legal guardians. Parents of students who are suspected of or identified with a disability under the Individuals with Disabilities Education Act are provided with copies of the IDEA procedural safeguards. PARENT AND STUDENT RIGHTS UNDER SECTION 504: 1. Parents and students have the right to be informed by the School District of their rights under Section 504. The purpose of these Procedural Safeguards it to advise you of those rights. 2. A child with a disability has the right to a free appropriate public education designed to meet his or her individual educational needs as adequately as the needs of nondisabled peers are met. This includes the right to be educated with nondisabled students to the maximum extent appropriate. It also includes the right to have the school district make reasonable accommodations to allow the student an equal opportunity to participate in school and school-related activities. 3. A child with a disability has the right to free educational services except for those fees that are imposed on nondisabled students or their parents. It should be noted that, under the law, insurers and other third parties are not relieved from an otherwise valid obligation to provide or pay for services for a disabled student. 4. A child with a disability has the right to take part in, and receive benefits from, public education programs without discrimination because of his/her disability. 5. The parent(s) of a child with a disability have the right to receive notice with respect to the identification, evaluation, or placement of the child. 6. A student with a disability has the right to receive services and be educated in facilities that are comparable to those provided to nondisabled students. 7. A student with a disability has the right to have evaluation, education and placement decisions made based on a variety of information sources, and by persons who know the student and are knowledgeable about the evaluation data and placement options. The student also has the right to be periodically reevaluated. 8. A student with a disability has an equal opportunity to participate in nonacademic and extracurricular activities offered by the District.


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9. A student with a disability has the right to have transportation provided to and from an alternative placement setting (if the setting is in a program not operated by the District) at no greater cost to the parent than would be incurred if the student were placed in a program operated by the District. 10. The parent of a student with a disability or an eligible student (over 18) has the right to examine all relevant records relating to decisions regarding the student’s identification, evaluation and placement. 11. The parents of a student with a disability or an eligible student have the right to request an impartial due process hearing relating to decisions or actions relating to the student’s identification, evaluation, program or placement. The procedures for requesting an impartial due process hearing are described below. 12. The parents of a student with a disability or an eligible student have the right to file a local grievance with the District for issues unrelated to the identification, evaluation, program or placement of the student. Board policy _____ describes the procedures for filing a grievance and can be requested by contacting: _________________________________. Persons who believe that the District is discriminating against eligible persons on the basis of disability may also file complaints with the District’s Section 504 Coordinator and/or the Office of Civil Rights, Kansas City Office, U.S. Department of Education, 10220 North Executive Hills Blvd., 8th Floor 07-6010, Kansas City, MO 64153-1367. The District’s Section 504 Coordinator is ___________________ and may be reached at _____________________________. DUE PROCESS APPEAL PROCEDURES: This procedure should be used if the parent, legal guardian or eligible student intends to challenge actions proposed or refused under 504 by the District regarding the identification, evaluation, program or placement of a student with a disability. 1. If a parent, legal guardian or eligible student intends to challenge the action proposed or refused by the District, the parent/guardian or eligible student must filed a written Notice of Appeal within ten (10) [or other time frame] calendar days from the time that the parent/guardian or eligible student receives written notice of the proposed or refused action. The Notice of Appeal should be filed with: ___________________________________ 2. The Notice of Appeal must state the specific circumstances, including all relevant facts, giving rise to the request for due process; the specific issues to be decided at the impartial due process hearing; and the relief being requested. The District will acknowledge, in writing, all Notice of Appeal, within 5 school days of receipt. 3. The District will, within ten (10) school days of the District’s receipt of the Notice of Appeal, appoint and retain a single impartial hearing officer to hear and decide the Notice of Appeal. The hearing officer must have knowledge or training in Section 504 and may not be an employee of the


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District. The hearing officer may not have a personal or professional interest that would conflict with his/her objectivity in the hearing. The District is not required to consult with the parent/guardian or eligible student with respect to the hearing officer appointment. 4. Upon receipt of the Notice of Appeal, the Superintendent, or his/her designee, will promptly investigate the circumstances giving rise to the hearing request. That investigation shall not delay the District’s processing of the request for hearing. In addition, within ___ days of the receipt of the Notice of Appeal, the Superintendent, or his/her designee, will contact the parent/guardian or eligible student in an attempt to find a resolution to the issues stated in the Notice of Appeal. The parent/guardian or eligible student will be invited to participate in an information resolution meeting to give the parent/guardian or eligible student an opportunity to discuss the matters in dispute in an effort to resolve those matters without a need for a hearing. The parent/guardian or eligible student is not required to participate in such a meeting and the parent/guardian or eligible student’s refusal to participate in such a meeting cannot delay or eliminate the right to an impartial hearing. 5. The parties to the hearing have the following rights: a. The right to inspect all relevant records, including personally identifiable records of the student; b. The right to be represented and advised by an attorney; c. The right to present evidence and confront, cross-examine and compel the attendance of witnesses; d. The right to obtain a record of the hearing; e. The right to obtain written findings of fact, conclusions of law, and decision. 6. The hearing officer must hold the hearing within ____ days of his/her appointment as hearing officer. If the hearing officer’s schedule does not permit a hearing within ___ days, a hearing may be held, for good reason, outside of this ___ day period. 7. The hearing officer shall render a final, written decision no later than ___ days following the completion of the hearing. A decision may be rendered after ___ days, for good cause shown. The decision of the hearing is final and binding, subject to the judicial review procedures outlined below. 8. The ___ School District is responsible for costs directly attributable to the provision of administration hearings described in these procedures, including compensation of the hearing officer, transcripts or recordings of the hearing, and other related expenses. The District is not responsible for the costs of legal counsel or other representative of the parent/guardian or eligible student or for the costs of producing or reproducing the evidence presented by the parent/guardian or eligible student. 9. Any timelines specified herein may be extended by agreement of the District and parent/guardian or eligible student or by order of the hearing officer. 10. Any party aggrieved by the decision of the impartial hearing officer may appeal that decision to any court of competent jurisdiction.


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504 NOTICE OF APPEAL

(Request for an Impartial Due Process Hearing Under Section 504) Student’s Name:________________________________________________________________ Parent/Guardian Name:___________________________________________________________ Address/Phone Number:__________________________________________________________ I am in disagreement with the following decisions made by the District pertaining to my child’s identification/evaluation/educational placement under Section 504: Please describe the circumstances/ facts giving rise to the disagreement: (Please state the background leading to the disagreement and why you disagree with the District’s decision). Please state the specific issues to be decided at the hearing: Please describe the relief requested (what result you would like the hearing officer to provide if the hearing officer decides in your favor): ______________________________________________ ________________________ Signature of parent/guardian Date of signature

504 PROCEDURES MANUAL

Documents

Transcript of 504 PROCEDURES MANUAL