School District Form 504-4r

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SCHOOL DISTRICT OF xxx
FORM 504-4R
PLACEMENT/ACCOMODATION PLAN
Name: ________________________
DOB:
Sex:
Grade:
Parent/Guardian:
_________________________
Phone:
___________
Address:
____________________________________
School: ________________________________Case Manager: ____________________
Review Team Members
Name
Signature
Date
_________________________
________________________
______________________________
_________________________________________________
Evaluation Information Considered:
(Student name) has a documented history of Phenylketonuria (PKU), a rare inherited
error in metabolism, in which the person is unable to convert an essential amino acid
called phenylalanine. PKU is a treatable disorder that requires a carefully calculated diet
that is extremely low in phenylalanine and a medical formula that is used as a nutritional
substitute. This treatment requires close supervision to avoid life altering conditions that
are caused by not following the diet.
Determination of Handicap: No
Yes
X
Check all the reasons/criteria which apply: (A student qualifies for 504 with only one criteria
checked)
X
1. Has a physical or mental impairment which substantially limits one or more life
activities;
X
2. Has a record of such impairment;
X
3. Is regarded as having such an impairment
Identify Impairment: PKU
Identify life activities: Eating, metabolic, all life activities if not controlled
Referral to Special Education
The 504 Team has determined that this student may be eligible to be considered as
educationally disabled under IDEA:
X
No
Yes

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