Section 504 Student Services Plan (Page 2 of 4) in pdf

Form 12, page 2 of 4

Student Name:

Student ID:

Campus:

Grade:

This Plan WILL BE implemented, beginning on:

and will continue until:

OR will continue until the Plan is replaced or student is exited

This Plan WILL NOT be implemented due to the parent’s refusal of consent for initial Section 504

services or revocation of consent for continued Section 504 services.

Required Services & Accommodations (by course). The following form is used to document the student’s placement

under Section 504. While checklist forms are convenient, they are also subject to confusion. Eligibility for a Plan does

not mean that every service or accommodation available under Section 504 is appropriate for every child. Individual

needs determined during evaluation should guide services decisions. For questions or concerns about the §504 Plan,

contact ________________________________, the designated §504 administrator or designated §504 coordinator.

As the descriptions used here are brief, please use

List courses from student’s schedule and indicate services and

the notes page to ensure appropriate

accommodations required for each class.

understanding and implementation for items

checked. Note also that the following items are

not the only services or accommodations available

under §504. Attach additional pages if necessary.

Oral Testing

Oral Response

Other Testing Accommodation (type?)

Taped Texts

Taped lecture

Note-taking assistance

Extended Time (by %)

Shortened Assignment (by %)

Peer assistance/tutoring

Reduced paper/pencil tasks

Use of calculator

Preferential seating

Assignment notebook

Organizational strategies (type?)

Re-teach difficult concepts

Use of manipulatives

Team teaching

Supplemental materials

Cooling-off period

Progress reports (frequency?)

**SEE ATTACHED DYSLEXIA

ACCOMMODATIONS FORM

Does the student need a behavior plan? Yes ____ No ____

[If yes, page 3 must be completed and attached]

Does the student require reasonable modification of policies, practices or procedures? Yes ____ No ____ . If yes,

please explain on the notes and information page.

Does the student receive health plan services? Yes ___ No ___ If yes, please attach the health plan.

Texas Dyslexia Services (Form 15): For students eligible under the Texas Dyslexia Law, are dyslexia services

required? If so, __hours per week/month/semester of dyslexia services will be provided. (Please circle time frame)

Accommodations on statewide assessment:

Related Services (provide detail on information and notes page)

Tutorials

Counseling

Transportation

Other: ____________________________________

General Education Homebound (Form 16) ___ hours of homebound instruction per week pursuant to Form 16

THIS PLAN IS CONFIDENTIAL and should only be made available to individuals with a legitimate educational

interest or as otherwise allowed by FERPA.

Section 504 Service Plan

Section 504 Student Services Plan Page 2

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