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REQUEST FOR SECTION 504 ACCOMMODATIONS 2017-2018

Name of Student

DOB

Student ID#

School Name

School ATS/DBN:

Grade/Class

Name of Requesting Parent/Guardian

Relationship to Student:

Date Submitted to the 504 Coordinator

Name of 504 Coordinator

To be completed by the parent/guardian; submit to the school 504 Coordinator

PART 1:

Describe the concern below and how it affects the student’s educational performance:

Indicate accommodations requested based on the concern above. Please consult the school-based 504 Coordinator with any questions.

Request for Educational Accommodation(s)

For school use only

Check all requested:

Approve

Deny

□

Testing

Test schedule/administration time (e.g. extended time, etc.)

Accommodations

□

Test setting/location

□

Method of presentation/Directions/Assistive Technology

□

Method of test response/content support

□

Other (please specify)

□

Classroom /

Class schedule/use of time

Curriculum

□

Class activities setting

Accommodations

□

Method of presentation/Directions/Assistive Technology

□

Method of class activities response/Content Support

□

Other (please specify)

□

Academic Supports

 new request

 renewal request

Health Paraprofessional*

and Services

□

Safety Net (high school only)

□

Other (please specify) ________________________________________________

□

Other Accommodation

(please specify)**

□

* Paraprofessional requests must be reviewed by an Office of School Health Physician in order to determine medical necessity. Additional forms must be completed; please check with your 504

Coordinator.

**Transportation Requests: A Medical Evaluation Request form, available on the DOE website, must be used for specialized transportation accommodations.

Part 2: PARENT CONSENT - To be completed by the student’s parent/guardian prior to submitting to School 504 Coordinator

To determine whether your child is eligible for accommodations under Section 504 of The Rehabilitation Act of 1973, a school-based 504 team will convene

to review your child’s records, including the physician’s statement (if applicable), classroom observations and assignments, assessment data, and other

information. If your child is eligible to receive accommodations, a 504 Plan will be developed with your input and consent. The 504 Plan may be reviewed at

any time, but at a minimum must be reauthorized each school year.

By signing this form, you are giving consent to the 504 team to review your child’s records and take the necessary steps to determine whether your child is

eligible to receive accommodations. You also acknowledge that you have provided full and complete information to the best of your ability and understand that

the Office of School Health (OSH), New York City Department of Education (DOE), their agents, and their employees are relying on the accuracy of the

information provided to determine whether and to what extent your child may receive accommodations under Section 504. Additionally, you hereby authorize

OSH and DOE and their employees and agents, to contact, consult with and obtain any further information they may deem appropriate relating to your child’s

medical condition, medication and/or treatment, from any health care provider and/or pharmacist that has provided medical or health services to your child.

□

Completed HIPAA form attached (REQUIRED FOR REVIEW; PARENTS MUST COMPLETE THE BACK OF THIS FORM).

Name of Parent/Guardian __________________________________

Daytime Phone Number __________________

Signature of Parent/Guardian _______________________________

Date __________________________________