Section 504 Individual Accommodation Plan (Iap) Template - Louisiana Department Of Education Page 4
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4IAP Form – Page 4 of 4
CONFIDENTIAL
LDE 07/2013
SECTION 504
INDIVIDUAL ACCOMMODATION PLAN (IAP)
__________________________________
________________
Local Educational Agency (LEA)
Student______________________________________ I.D. # _______________________School____________________________
Last
First
Part J. Compensatory Services (Specify)
(01) Multisensory Structured Language Program(s) (Bulletin 1903 Guidelines) (Specify) __________________________________
(02) 3-Tier Intervention Model ________________________________________________________________________________
(03) Remediation/Tutoring ____________________________________________________________________________________
(04) Title I Services__________________________________________________________________________________________
(05) Other: ________________________________________________________________________________________________
Part K. Special Considerations
(01) Parent programs or agency involvement suggested (Specify) _____________________________________________________
(02) Alert bus driver or other personnel (Specify) __________________________________________________________________
(03) In-service school personnel involved with the student on the disability _____________________________________________
(04) Suggest interventions strategies for periods of transition (e.g., changing classes, PE, cafeteria et al) (Attach details)__________
(05) Other: ________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
If materials in more appropriate format are required for testing (e.g. large print), specify format and reason below.
______________________________________________________________________________________________________
The listed accommodations must be appropriate and must not subvert the purpose of the test or violate test
security. Check with the District Section 504 Coordinator, School Test Coordinator, and/or District Test
Coordinator for the appropriateness of other accommodations not listed above.
Part L. Signatures of 504/SBLC Members Participating in the Individual Accommodation Plan [ Required Signatures]
___________________________________
__________________________________
________________________________
Teacher / Date
Parent(s) / Date
School Test Coordinator / Date
Signature is required if student needs
accommodations for standardized
_______________________
__________________________________
______________
assessment.
Principal / Designee / Date
504/SBLC Member / Date
___________________________________
__________________________________
________________________________
504/SBLC Chairperson / Date
Student / Date
LEA 504 Coordinator / Date
Signature is required if student needs
accommodations for standardized
Part K. Notification of Parent Rights must be documented on this form or on alternate form
assessment.
and maintained with confidential records at all times. Please attach alternate form that
documents notification of parental rights (if applicable).
I have received a copy of Notice of Parent Rights & Grievance Procedures. __________________________________
Parent / Date
The Louisiana Department of Education and the Local Educational Agency are public service
agencies that do not discriminate in employment or educational services on the
basis of race, sex, religion, age, disability, or national origin.
Form 4b
Copy to parent, 504 district office, original in student’s 504 folder
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