Section 504 Accommodation Plan Template

Student Name: [Name]
Student ID: [ID]
School: [School Name]
Grade: [Grade]
Date of Plan: [Date]
Next Review Date: [Date]

Eligibility Determination

• Disability: [Describe impairment]
• Impact on major life activities: [Learning, concentrating, walking, etc.]
• Basis for eligibility: [Evaluations, medical reports, teacher observations]

Team Members

Student Profile

• Strengths and interests
• Areas of need
• Relevant medical/behavioral considerations

Accommodations and Services

Classroom Accommodations

• [Preferential seating]
• [Extended time for assignments]
• [Breaks during instruction]
• [Use of technology or assistive devices]

Testing Accommodations

• [Extended time]
• [Small group or quiet setting]
• [Alternate format (large print, scribe)]

Instructional Supports

• [Modified assignments]
• [Study guides/organizational aids]
• [Check-ins with counselor]

Health/Medical Supports

• [Medication administration plan]
• [Emergency action plan]
• [Restroom or nurse access]

Transportation (if applicable)

• [Special transportation arrangements]

Staff Responsibilities

• Teachers implement accommodations and monitor effectiveness.
• 504 coordinator ensures plan dissemination and compliance.
• School nurse manages health-related accommodations.

Progress Monitoring

• Method for tracking effectiveness (teacher reports, grade monitoring, behavioral data).
• Schedule for communicating with parents/guardians.

Parent/Student Rights

• Provide procedural safeguards notice and contact information for 504 coordinator.

Review and Revision

• Plan reviewed annually or as requested due to change in needs.
• Document revisions and date of implementation.

Signatures

• Parent/Guardian acknowledgment of receipt: __________________________ Date: __________
• 504 Coordinator: __________________________ Date: __________

Maintain confidentiality and ensure all staff working with the student receive copy of accommodations.