Section 504 Plan/chapter 15 Service Agreement
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SECTION 504 PLAN/CHAPTER 15 SERVICE AGREEMENT
Student Name:
John Doe
Date of Birth:
3/25/94
th
School:
ABC Middle School
Grade:
10
Date Services will begin:
8/28/2009
Date Services Will End:
6/15/2012
Initial Agreement:
For the 09-10 SY
Modified Agreement:
________
1.
Describe the nature of the concern:
John has a diagnosis of osteoporosis, Crohn’s Disease, and depression. Due to his condition,
John often experiences severe fatigue and nausea and becomes unable to focus on the tasks at
hand. His ability to participate in physical activity is also limited. Although John is currently
taking medication to relieve his symptoms, his condition will cause him to miss school, and, as a
result, he will miss classroom instruction, tests, and deadlines for completing homework
assignments. He will also not always be able to participate fully in physical education classes.
2.
Describe the basis for the determination of a physical or mental impairment:
Diagnosis of Dr. Mark Smith, gastroenterologist at CHOP, and diagnosis of Dr. Elaine Woods,
child psychiatrist at St. Christopher’s Hospital for Children, and diagnosis or Dr. Joe Miller,
pediatrician.
3.
Describe how the physical or mental impairment substantially limits a major life activity:
As a result of John’s physical impairments and his depression, he had difficulty concentrating in
school and he often experiences severe fatigue and nausea and becomes unable to focus on
learning and unable to think clearly. He is also substantially limited in his ability to stand and
bend due the osteoporosis.
4.
Describe the aids, services, and/or accommodations that are necessary:
Within two weeks of the beginning of courses during the school year, the guidance
counselor will provide to John’s parents the outlines or syllabi of John’s courses. In
the event an outline to a specific course does not exist, the teacher(s) will provide to
the parents a bi-monthly “syllabus” of assignments.
John’s teachers will provide weekly progress reports to John’s parents by e-mail. In
case John is absent, the guidance counselor will forward these reports to the family by
e-mail.
John and the guidance counselor will arrange bi-weekly meetings to discuss his
program, assignments, or any other issues.
John will receive additional in-school counseling services through the Student
Assistance Program.
If John is absent from school because of his medical condition, his teachers will allow
him a reasonable amount of time to make up missed assignments, tests, and return
library books. The allowable time will be determined by the length of his absence.
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